OIG Final Rule Expands Exclusion Authorities

February 2017 ~

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued a final rule expanding the authority to exclude individuals and entities from federal health care programs.

Implementing new and revised exclusion authorities from the proposed rule issued in May 2014, the final rule expands the exclusion regulations applicable to persons or entities receiving funds, directly or indirectly, from federal health care programs as well as spells out provisions set forth in the Patient Protection and Affordable Care Act (ACA) and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Major Provisions in the Final Rule set to become effective as of February 13th include:

  • Expanded Authorities for Granting Waivers
    • Expansion of the OIG’s authority to grant waivers of certain exclusions that are requested by the administrator of a federal health care program.
  • Expansion of Definitions
    • Clarification of changes to key terms, such as “directly,” “furnished,” and “indirectly,” to make clear that federal health care programs make payments through methods other than fee-for-service claims. The term “submit claims to” has been changed to “request or receive payment from” to further clarify the scope of the exclusion authority.
  • Obstruction of Audits
    • Expansion of the OIG’s authority to exclude individuals and entities convicted of obstructing an investigation to include audits, including those related to funds received from a federal health care program.
  • False Statements or Misrepresentation of Material Fact
    • Expansion of the OIG’s authority to exclude individuals or entities for making false statements, omissions or misrepresentations in an enrollment or similar application to participate in the federal health care programs, including Medicare Advantage organizations, Medicare prescription drug plan sponsors, Medicaid-managed organizations, and entities that apply to participate as providers or suppliers in organizations or plans.
  • Intent to Exclude and Oral Argument
    • The addition of the option for individuals and entities may present oral arguments to the OIG prior to exclusion.
  • Failure to Provide Payment Information
    • Expansion of the OIG’s authority to exclude a person for failing to supply (or allow the examination of) payment information by the secretary or a state health care program to apply not only to persons who furnishing services, but also to those referring or certifying the need for items or services.
  • Early Reinstatement
    • Establishing an early reinstatement process to assist beneficiary access and promote employment of individuals who obtain a new license or seek employment in non-licensed positions, as well as shortened the presumption against reinstatement from five to three years for individuals without any health care licenses who seek reinstatement.
  • Statute of Limitations
    • Establishes a 10-year statute of limitations for exclusion actions to align with the limitations period under the False Claims Act (FCA.

Full details on the final rule are available via the Federal Register(pdf).


Source(s): Federal Register, January 12, 2017; HDJN, January 16, 2017; FierceHealthcare, January 16, 2017; Lexology, January 19, 2017; Exclusion Screening, January 24, 2017