If you are a licensed healthcare provider who has been excluded from participation in federally funded health care programs, your reinstatement is neither automatic nor guaranteed.
Exclusion of individuals and entities from participation in any federal health care program is codified in the Social Security Act (the “Act”) and means that you must cease billing all federally funded health care programs, like Medicare and Medicaid, to name a few. Also, your reputation in the community will be called into question as your name will appear on the List of Excluded Individuals and Entities (“LEIE”) which is maintained by the Office of the Inspector General (“OIG”).
Clients often ask for examples of reasons why exclusion is imposed by the Secretary of the Department of Health and Human Services. For example, felony convictions involving patient abuse, health care fraud or dispensing of controlled substances will result in mandatory exclusion. For misdemeanor convictions relating to fraud, obstructing an investigation or audit, or dispensing of controlled substances, or license revocation/suspension, kickbacks and other prohibited activities by individuals or entities for which the Secretary determines to have violated the Act, these will likely result in permissive exclusion.
Once you receive notice from Medicare that you have been excluded, you have 60 days to appeal the decision. Once the time to appeal has passed, you will be bound to the terms and period of exclusion stated in the notice, which may be five (5) or even (10) years. Here, an experienced health care attorney can provide invaluable assistance in protecting your rights when dealing with the OIG.
If you entered into a Settlement Agreement with the United States Attorney, your agreement would likely contain a provision outlining when you are eligible to apply for reinstatement. Notwithstanding the above, if you have been excluded, you may apply for reinstatement no sooner then 90 days from the date the exclusion expires.
When seeking reinstatement, the excluded individual or entity must submit a written request to OIG and provide a statement that will serve to convince the OIG that you are not a risk to the federally funded health care programs or their beneficiaries. Once evaluated, OIG will send notification of its decision. Should OIG deny the application for reinstatement, the excluded individual or entity may not apply for reinstatement for one calendar year.
How you handle being notified of exclusion may materially affect several years of your professional practice, so obtaining assistance from a qualified and experienced health law attorney is essential from the beginning. For questions or to schedule a consultation, you may contact any of the health care attorneys at Weiss Zarett Brofman Sonnenklar & Levy, P.C.
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