What You Need to Know About Medicare & Medicaid Exclusion

January 10, 2017 by Antonio Arias, MBA, CHBME

Topics: Meaningful Use Stage 2, Practice Management, Medical Billing Company

Among most doctors and other healthcare professionals, concern over Medicare and/or Medicaid exclusion comes down to compliance: To avoid civil money penalties (or ‘CMPs’), providers are supposed to check that their employees and contractors are not on the Medicare exclusion list of the Office of the Inspector General (OIG).

With fines on the rise, the failure to properly screen for excluded employees or contractors is a significant risk for providers that should not be ignored. But screening new hires against a list of excluded persons isn’t the only way doctors need to stay on guard.

Recent incidents show that it isn’t just employees who can be barred from involvement with Medicare & Medicaid; doctors themselves can also become excluded from participating in the programs altogether. In November 2016, a New Jersey-based OB-GYN was barred from Medicare and Medicaid for twenty years for submitting false claims.

Though the physician was also subject to a $5.25 million fine, the action represents a shift from past years in which the consequences of false claims submittal were primarily financial, rather than career-ending. Gregory E. Demske, chief counsel to the HHS inspector general, went so far as to warn doctors to pay attention to the case.

"Twenty years is a substantial period of exclusion and is a clear signal to physicians that they face significant consequences, beyond monetary penalties, for taking advantage of federal health care programs and their beneficiaries," Demske said.

While the practice of Medicare exclusion isn’t new, it has been relatively rare and limited primarily to the most egregious of medical billing instances. Following the finalization of the November case, providers are reminded to stay especially diligent about the seriousness of their medical billing practices; Demske’s comments, made on November 15, 2016, may be a warning sign that Medicare exclusion will be more common in 2017 and coming years.

Amid such a “clear signal,” providers are reminded to contract only with well-vetted employees and third parties. One way to avoid allowing sketchy billing practices to slip through the cracks is to work with an experienced medical billing service that can provide you with third-party references and proven efficacy results. To get started, contact us now.


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