New Exclusion Rules to Take Effect Next Month

Earlier this month, the Health and Human Services Office of the Inspector General (HHS-OIG) finalized its long-awaited rules on civil monetary penalties that could make it easier for providers to be excluded from participating in the Medicare and Medicaid programs.

The final rule, which was published in the Federal Register on January 12, was first proposed in 2014 and updates HHS’ exclusion authority to include those who are found guilty of obstructing audits. Previously, only those convicted of obstructing criminal investigations faced program exclusion.

The final rule, which takes effect Feb. 13, builds on changes implemented by the Affordable Care Act to expand OIG’s authority even more.

The new rule did, however, implement a 10-year statute of limitations, which the OIG noted “addresses the commenters’ concerns about administrative burden and courts’ historical favoring of an enumerated limitations period.â€

On average, OIG noted that it excludes approximately 3,500 healthcare providers per year.

The length of exclusion is determined by a number of factors including: previous convictions for healthcare fraud, the amount of the financial loss, and the reason for the exclusion.

In Fiscal Year 2016, HHS-IG excluded 3,635 individuals and entities from participating in Medicare, Medicaid and other federal healthcare programs, according to a just-released report issued by HHS and the Department of Justice (DOJ).

Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (1,362) or to other healthcare programs (262), for patient abuse or neglect (299), and as a result of licensure revocations (1,448). HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would correct program vulnerabilities and save program funds.

The annual health care fraud and abuse report states that the federal government won or negotiated more than $2.5 billion in healthcare fraud judgments and settlements during fiscal year 2016. That’s up from $1.9 billion in FY 2015. As a result of those efforts, as well as those of preceding years, more than $3.3 billion was either returned to the federal government or paid to private citizens.

The DOJ reported that it opened 975 new criminal healthcare fraud investigations in 2016, with federal prosecutors filing criminal charges in 480 cases involving 802 defendants. A total of 658 defendants were convicted of healthcare fraud-related crimes in FY 2016.

There were 930 new civil healthcare fraud investigations opened in 2016 and 1,422 civil healthcare fraud matters pending at the end of the year.

Investigations conducted by HHS-OIG resulted in 765 criminal actions against those who engaged in crimes relating to Medicare and Medicaid and 690 civil actions, which included false claims and unjust enrichment lawsuits, civil monetary penalty settlements and administrative recoveries related to provider self-disclosure matters.

The federal government has continued to make healthcare fraud a priority. Providers and suppliers should be aware of the new policy changes taking effect next month. Feel free to contact us for additional information at 305-358-4500 or send us an email to and let’s discuss how we might be able to assist you.

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The Health Law Offices of Anthony C. Vitale