The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued a final rule expanding the authority to exclude individuals and entities from federal health care programs. The final rule implements new and revised exclusion authorities from the proposed rule issued on May 9, 2014. Further, the rule clarifies provisions set forth in the Patient Protection and Affordable Care Act and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Key highlights of the final rule include:
- Statute of Limitations – The OIG codified a ten-year statute of limitations period for exclusion actions to align with the limitations period under the False Claims Act (FCA). This provision will allow the OIG and the United States Department of Justice to better coordinate and resolve exclusions in conjunction with FCA settlements.
- Expansion of Definitions – The final rule redefines key terms, including “directly,” “furnished,” and “indirectly,” to clarify that federal health care programs make payments through methods other than fee-for-service claims. The OIG also changed the term “submit claims to” to “request or receive payment from” to further clarify the scope of the exclusion authority.
- Obstruction of Audits – The OIG may exclude individuals and entities convicted for interfering with or obstructing an investigation or audit, including those related to funds received from a federal health care program.
- Early Reinstatement – The final rule establishes 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. Further, the OIG shortened the presumption against reinstatement from five to three years for individuals without any health care licenses who seek reinstatement.
- Failure to Provide Payment Information – The OIG may exclude any individual or entity that fails to provide payment information to federal health care programs upon request.
- Intent to Exclude and Oral Argument – If the OIG intends to exercise its exclusion authority, individuals and entities may present oral arguments to the OIG prior to exclusion; and
- False Statements or Misrepresentation of Material Fact – The OIG may exclude individuals or entities that have knowingly made or caused to be made a false statement, omission, or misrepresentation of a material fact. The OIG may consider the impact of exclusion on:
- Beneficiary access to care;
- The nature and circumstances of the conduct;
- The extent of payments requested or received; and
- The individual or entity’s history of criminal, civil, or administrative wrongdoing.
The final rule will take effect on February 13, 2017.
The final rule is available at: