RCPA - Rehabilitation and Community Providers Association


Bulletin on Effect of Exclusion from Federal Health Care Programs Updated
May 26, 2013

The Department of Health and Human Services Office of the Inspector General (OIG) has issued Updated, Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs to update the original 1999 bulletin. The revised bulletin identifies the impact of the prohibition on payment by federal health care programs for items or services furnished by an excluded person, or at the medical direction or on the prescription of an excluded person. It describes administrative sanctions that can be used against violators. The bulletin also describes screening of employees and contractors for exclusion.

No federal health care program payment may be made for any items or services furnished by an excluded person or at the medical direction or on the prescription of an excluded person. The exclusion continues even if the individual changes from one health care profession to another. The payment prohibition applies to items or services provided beyond direct care and services, such as inputting data related to care and services or any administrative or management services, including health information technology services, strategic planning, and billing. Excluded persons are also prohibited from providing transportation services paid by federal health care programs.

Excluded persons who submit claims may be subject to civil monetary penalties of $10,000 for each claimed item or service provided during the exclusion period. The person may also be subject to an assessment of up to three times the amount claimed for each item or service. Additionally, criminal prosecution or other civil actions may be undertaken. An exclusion does not prohibit the person from owning a provider that participates in federal health care programs, but the OIG may exclude the provider under certain circumstances, such as ownership of a five percent or more interest in the provider. The provider may not seek federal payment for any services, including management services, provided by the excluded owner. A provider could be subject to CMP if an excluded person provides items or services payable by a federal health care program, even if the excluded person does not receive payment from the provider for the service (e.g., a volunteer).

Providers must check the List of Excluded Individuals and Entities to determine whether individuals are excluded. OIG suggests maintaining documentation, such as printed screens, of resultant searches. The OIG holds providers liable for employment of excluded individuals even if screening is done by a contractor. As described in Medical Assistance Bulletin 99-11-05, Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs and the Effect of Exclusion on Participation .Pennsylvania requires monthly screening and also requires checks of the Excluded Parties List System (EPLS) maintained by the General Services Administration, and the Medicheck List. The EPLS was recently merged with the System for Award Management.  Address questions to Betty Simmonds

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