Tuesday, February 24, 2015

OIG Discusses Effects of Exclusion from Federal Health care Programs

Dianne De La Mare 

The US Department of Health and Human Services, Office of Inspector General (OIG) has issued an Advisory Opinion (AO) in response to a question from an excluded provider about payments for services performed prior to the effective date of his/her exclusion from the federal health care programs. OIG determined that in this instance, the excluded provider was entitled to receive payment from the buyer of his/her medical practice for services furnished prior to exclusion from the federal health care programs.

Pursuant to a criminal plea and a civil False Claims Act (FCA) settlement, an individual provider was excluded from participation in the Federal health care programs for a period of 20 years. The effective date of the exclusion was October 25, 2013. Under the terms of that global settlement, the provider also was required to divest all ownership of his medical practice. The sale of the practice’s assets were finalized in an agreement dated October 31, 2013. Prior to the exclusion date, the individual provider performed services and submitted claims for services but the federal government did not make any payments for these services until after the individual’s exclusion date. In selling his/her medical practice, the excluded individual negotiated with the buyer that it would remit all payments received from the federal government prior to his/her exclusion date for services that the individual provider had furnished.

According to the OIG, under the Social Security Act, Section 1128, no payment can be made by any federal health care program for any items or services furnished directly or indirectly to an excluded individual. However, in this specific case, OIG distinguished the individual provider’s situation because the services were furnished before the effective date of the exclusion. Therefore, OIG concluded that in this specific instance, receiving payment from the buyer for services after the exclusion date did not violate the terms of the provider’s exclusion and would not give rise to additional administrative sanctions.

To obtain the complete OIG AO go to https://oig.hhs.gov/fraud/docs/advisoryopinions/2015/AdvOpn15-02.pdf.

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