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”