You’re Out! The OIG Finalizes Revisions to its Medicare and Medicaid Exclusion Authority

On Thursday, January 12, 2017, the Office of Inspector General at the U.S. Department of Health and Human Services (OIG) finalized its revisions to its rules for excluding individuals and businesses from participation in Federal Health Care Program, i.e. Medicare and Medicaid.

The revisions came about as a result of new and revised authorities found in the Affordable Care Act of 2010 (ACA) and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The revisions initially were proposed in an OIG proposed rule published on May 9, 2014.
There are some important new revisions in the final rule, they include:

– A ten year look-back period for possible exclusion.

–  New definitions for some key terms in the regulations, such as what it means to “furnish” goods or services either “directly” or “indirectly”. The new definitions, according to the OIG, align to a broader definition of the term “claim” found in the False Claims Act.

– A new process for early reinstatement in certain cases for providers who have been excluded after losing a license, including lapses in professional competence, professional performance or financial integrity.

– A higher threshold, $50,000 of government losses, for applying aggravating factors in a determination of how long an exclusion should last.

– A more detailed discussion of the OIG’s new exclusion authority relating to individuals and entities who were convicted for the interference with or obstruction of both investigations and audits.

– Clarification that individuals who refer patients or certify the need for items or services they themselves do not provide, can be subject to exclusion.

So, what do the new revisions mean to stakeholders in health care M&A transactions? They serve as a significant reminder of the necessity to ensure that acquisition targets don’t have exclusion related risks associated with them. Continue reading “You’re Out! The OIG Finalizes Revisions to its Medicare and Medicaid Exclusion Authority”


Watch Closely – Health Care Policy Changes 2017 and Beyond…

It is 2017 and we have a one party-controlled Federal government coming into power in Washington DC. We heard a lot during the presidential campaign and post-campaign about changes that may be coming to our health care system and the potential repeal or revision of significant health care reform policies .

The Republican controlled congress is already working hard on a repeal of the Affordable Care Act (ACA), it is clear they feel they have to deliver on campaign promises and party positions. What is unclear, however, is whether or not replacement legislation will accompany the repeal or follow shortly thereafter. Many health care insiders are concerned that a repeal without a well-designed replacement will create significant disruption. The American Medical Association (AMA) recently released an open letter to congressional leaders asking them to ensure that an appropriate replacement policy is in place before repeal efforts are concluded.

The AMA said in its letter “…we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.” Continue reading “Watch Closely – Health Care Policy Changes 2017 and Beyond…”