The purpose of excluding a provider from participating in federal health insurance programs is to protect federal healthcare programs from untrustworthy providers. As such, no federal health care program payment may be made for items or services: (i) furnished by an excluded individual or entity; or (ii) directed or prescribed by an excluded individual, where the person furnishing the item or service knew or had reason to know of the exclusion.
The Office of the Inspector General of the United States (“OIG”) is responsible for conducting audits, inspections, investigations and taking action against providers that violate certain rules and regulations that were enacted to protect the federal purse from fraud and abuse. A provider can be excluded from participating in federal health care programs by:
The OIG has broad discretion when excluding a provider from participating in federal health care programs. Nevertheless, the OIG criteria to exclude a provider must be based on the nature and circumstances of conduct, conduct during the Government’s investigation, significant ameliorative efforts, and history of compliance.
In addition, the Centers for Medicare and Medicaid Services (“CMS”) has the authority to suspend and/or revoke the billing privileges of health care providers. Deactivation means the temporary suspension of billing privileges without termination of the provider or supplier agreement. Revocation means automatic termination of the provider or supplier agreement, which is effective 30 days following notice unless based on final adverse action or non-operational location, then it’s effective as of the date of the adverse action or finding location to be non-operational.
CMS may revoke the billing privileges of any health care provider when:
Health care providers can file an appeal when CMS makes a final determination to either deactivate or revoke their billing privileges. To file an appeal a provider must file a Request for Reconsideration within 60 days of the notice of revocation. If CMS or its contractor, or the provider or supplier is dissatisfied with the Reconsideration Determination, they may request an Administrative Law Judge Hearing within 60 days from the receipt of the Reconsideration Decision. If CMS or its contractor, or the provider or supplier is dissatisfied with the ALJ Hearing Decision, they may request review by the Medicare Appeals Council within 60 days from receipt of the ALJ’s decision. Finally, a provider or supplier dissatisfied with the Medicare Appeals Council Decision may seek judicial review in Federal District Court by filing a civil action within 60 days from receipt of the Medicare Appeals Council’s Decision.