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For many years the Congress of the United
States has worked diligently to protect
the health and welfare of the nation's elderly
and poor by implementing legislation to
prevent certain individuals and businesses
from participating in Federally-funded health
care programs. The OIG, under this Congressional
mandate, established a program to exclude
individuals and entities affected by these
various legal authorities, contained in
sections 1128
and 1156
of the Social
Security Act, and maintains a list of
all currently excluded parties called the
List of Excluded Individuals/Entities.
Bases for exclusion include convictions
for program-related fraud and patient abuse,
licensing board actions and default on Health
Education Assistance Loans.
The effect of an exclusion (not being able
to participate) is:
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No payment will be made by any Federal
health care program for any items or
services furnished, ordered, or prescribed
by an excluded individual or entity.
Federal health care programs include
Medicare, Medicaid, and all other plans
and programs that provide health benefits
funded directly or indirectly by the
United States (other than the Federal
Employees Health Benefits Plan). For
exclusions implemented prior to August
4, 1997, the exclusion covers the following
Federal health care programs: Medicare
(Title XVIII), Medicaid (Title XIX),
Maternal and Child Health Services Block
Grant (Title V), Block Grants to States
for Social Services (Title XX) and State
Children's Health Insurance (Title XXI)
programs.
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No program payment will be made for
anything that an excluded person furnishes,
orders, or prescribes. This payment
prohibition applies to the excluded
person, anyone who employs or contracts
with the excluded person, any hospital
or other provider where the excluded
person provides services, and anyone
else. The exclusion applies regardless
of who submits the claims and applies
to all administrative and management
services furnished by the excluded person.
Additional information is available in
the Special
Advisory Bulletin on the Effect of an Exclusion.
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