What You Need to Know About the Medicaid & Medicare Exclusion List

October 4, 2021 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Practice Management

In 2019, more than 18% of Americans were covered by Medicare; in 2020 alone, Medicare’s budget exceeded $925 billion. This is an important population of the country for your medical practice, and being able to accept Medicare or Medicaid coverage means you can attract more patients.

But did you know there’s a list of medical practices that can’t file claims to Medicare or Medicaid? Here’s what you need to know about the Exclusion List.

What Is the Medicaid and Medicare Exclusion List?

As the name might suggest, the exclusion list compiles various offices, agencies, or individuals who can’t file claims for Medicaid or Medicare – thus they can’t accept patients who utilize these services. 

The Office of the Inspector General (OIG) is responsible for maintaining this exclusion list; when the OIG is considering excluding an individual or entity, the process of determining whether or not to exclude an entity varies depending on the basis for the proposed exclusion. OIG has been implementing exclusions since about 1981, but the Department of Health & Human Services first began imposing them in 1977.

There are two types of exclusions: mandatory and permissive. In either case, the health care provider will receive a written Notice of Intent to Exclude, which includes the basis for the proposed exclusion as well as a statement about the potential effect of the exclusion.

The person or entity has 30 days to provide the OIG with any relevant information and mitigating circumstances to show that the exclusion is not warranted. Mandatory exclusions are for a minimum five-year period and require a written request to be officially over. If the OIG proceeds with the exclusion, a Notice of Exclusion will be issued.

How Do Medical Practices Get on the Medicare Exclusion List?


With mandatory exclusions, the OIG is required by law to exclude entities that have committed certain types of criminal offenses from participation in Medicare and Medicaid programs. These offenses include:

  • fraud, as well as any other offenses related to the delivery of items or services under Medicare/Medicaid or other state programs
  • patient abuse or neglect
  • felony convictions or other healthcare-related fraud
  • theft or other financial misconduct
  • felony convictions related to unlawful manufacture, distribution, prescription, or dispensing of controlled substances

Under permissive exclusions, the OIG has the discretion to exclude individuals for:

  • misdemeanor convictions relating to healthcare fraud other than Medicare or a state health program
  • misdemeanor convictions relating to the unlawful manufacture, distribution, or prescription of controlled substances
  • suspension, revocation, or the surrendering of a license to provide healthcare for reasons bearing on professional competence, professional performance, or a financial integrity provision of unnecessary or substandard services
  • defaulting on health education loans or scholarship obligations

How to Avoid the Medicare Exclusion List: 3 Tips to Follow

Medical practices essentially wind up on the exclusion list for reasons related to fraud, theft, or abuse, but how can you ensure your medical practice avoids the list? Start with these tips:

Thoroughly Screen Employees and Contractors

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. Be sure to screen new hires against a list of excluded persons to stay on guard. 

Incorporating this additional measure in your hiring practice will add another layer of protection for your medical practice’s reputation – and potentially save you quite the headache.

Follow Best Practices for Filing Claims

Recent incidents show that it isn’t just employees who can be barred from involvement with Medicare and Medicaid; doctors themselves can also become excluded from participating in the programs altogether. 

For example, in November 2016, a New Jersey-based OB-GYN was barred from Medicare and Medicaid for 20 years for submitting false claims. It should go without saying, but be careful with the claims your medical practice files with Medicare and Medicaid.

Partner with an Experienced Medical Billing Agency

The truth is, some of the most successful practices use outsourcing services to simplify their medical practice and revenue cycle management

There are several benefits that a medical billing firm should provide your practice, including more time to work with patients, staying current on medical billing regulations, and optimizing your practice’s overall operations.

Best Practices for Medical Billing and Coding to Prevent Potential Errors


Your medical practice’s financial future is staked on being efficient and profitable, which starts with medical billing and coding practices. When you have an effective billing and coding process in place, you can prevent any costly errors that might land your practice on the Medicare and Medicaid exclusion list.

Start with these tips to optimize your revenue cycle!

Keep Your Clean Claim Rate Above 95%

Your medical practice’s clean claim ratio is the average number of claims paid on the first submission. In a perfect world, every provider would love to reach a percentage above 95%, but the meaning behind the number is what really matters. 

The higher your clean claim rate, the less valuable time your personnel will spend trying to identify denial reasons, coordinate payments, and re-submit claims.

Get a Grip on Your Accounts Receivable

How often do you track your receivables? Do you find yourself having to scramble for time to respond to a denied claim? 

Maybe you should reconsider how you manage your contracts and receivables. Coding changes happen quickly in the healthcare industry, and there’s no better time to get ahead of foreseeable issues.

Properly Submit Accurate Claims

It’s estimated that up to 80% of medical bills contain errors, resulting in weeks of editing, resubmission, and providers not receiving their reimbursement. This is why your first submission needs to be accurate. You want to avoid the wasted effort involved in editing and resubmitting incorrect claims.

Properly filling out claims and avoiding common errors, such as incorrect patient or insurance information and duplicate claims, can establish an efficient medical billing process for your medical practice. 

Trust Your Medical Billing and Collections to the Experts at NCG!

Choosing the right medical billing company when outsourcing your billing processes is incredibly important for building and sustaining a successful healthcare practice. No matter your specialty or unique needs, having the right medical billing services can make all the difference when it comes to an efficient billing process and improved revenue cycle management. Additionally, it helps with following best practices to keep your practice off of the Medicaid and Medicare exclusion list. 

At NCG Medical, we’ve been the outsourced medical billing experts for four decades by handling all the ins and outs of the medical billing process. Our customized solutions can improve revenue management cycles and ensure that your practice is receiving the most streamlined reimbursement process. Contact us today to learn more about how we can transform your medical billing.

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