WASHINGTON – While the line between an inadvertent billing mistake and intentional coding deception might be blurry, federal investigators are crystal clear about what drives them to exclude health providers from government health programs.
Rejection from Medicaid and Medicare comes down to severity and accountability, said Lisa Re, branch chief of administrative and civil remedies for the Health and Human Services Department Office of Counsel to Inspector General.
Lisa Re
“At the end of the day, what we’re looking at is the seriousness of the conduct, cooperation with the compliance program, and whether or not there’s been a sense of financial responsibility – that the program has been made whole from the harm that was done,” Ms. Re said at a meeting sponsored by the American Bar Association.
In 2015, the Office of Inspector General (OIG) excluded 4,112 individuals and entities from participation in federal health care programs, up from 4,017 in 2014, according to a the OIG’s semiannual report to Congress published Nov. 30.
The office expects to recover nearly $3.4 billion in incorrect payments in 2015, down from $4.9 billion last year. The office also reported 925 criminal actions and 682 civil actions in 2015 involving false claims, unjust-enrichment lawsuits, civil settlements, and administrative recoveries.
When it comes to exclusions, investigators rely on the facts and circumstances of each individual case, Ms. Re said. Certain behaviors such as repeated disregard of government inquires and ongoing overbilling can lead to exclusions.
“We’re not trying to punish anyone,” Ms. Re said. “Exclusion is purely remedial. It’s a question of whether or not you have demonstrated sufficient trustworthiness for us to continue doing business with you.”
The OIG considers two types of exclusions – mandatory and permissive. The agency is obligated to exclude a provider if that professional is convicted of program-related crimes, is convicted of patient abuse or neglect, receives a felony health fraud conviction, or is convicted of two mandatory exclusion offenses. The OIG can use its discretion in situations in which a provider receives a misdemeanor conviction related to health fraud, has a license suspended or revoked, fails to disclose required information, fails to take corrective action, or makes false statements to the government, among others. Reinstatement of excluded entities and individuals is not automatic once the exclusion period ends. Those wishing to again participate in a federal health care program must apply for and receive reinstatement permission from the OIG.
Ms. Re stressed that her office is transparent about possible or upcoming exclusions during a payment investigation. If health professionals come under billing scrutiny, she encourages them and their attorneys to contact OIG officials to inquire whether an exclusion is likely or expected.
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