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OIG PROGRAM EXCLUSION AUTHORITIES
(footnotes relate to effective
dates)
SCOPE
SOCIAL SECURITY ACT
|
42
USC § |
Amendment |
1. 1128^ |
1320a-7 |
Scope of exclusions imposed
by the OIG expanded from Medicare and State
health care programs to all Federal health
care programs, as defined in section 1128B(f)(1). |
MANDATORY EXCLUSIONS
SOCIAL
SECURITY ACT |
42
USC § |
Type |
1. 1128(a)(1) |
1320a-7(a)(1) |
Conviction of program-related
crimes. Minimum Period: 5 years |
2. 1128(a)(2) |
1320a-7(a)(2) |
Conviction relating to
patient abuse or neglect. Minimum Period:
5 years |
3. 1128(a)(3)*
|
1320a-7(a)(3) |
Felony conviction relating
to health care fraud. Minimum Period:
5 years |
4. 1128(a)(4)*
|
1320a-7(a)(4) |
Felony conviction relating
to controlled substance. Minimum Period:
5 years |
5. 1128(c)(3)**(G)(i)^
|
1320a-7(c)(3)(G)(i) |
Conviction of two mandatory
exclusion offenses. Minimum Period: 10
years |
6. 1128(c)(3)**(G)(ii)^
|
1320a-7(c)(3)(G)(ii) |
Conviction on 3 or more
occasions of mandatory exclusion offenses.
Permanent Exclusion |
7. 1892 |
1395ccc |
Failure to enter an agreement
to repay Health Education Assistance Loans
(HEAL). Minimum Period: Until entire past
due obligation is repaid. |
PERMISSIVE EXCLUSIONS
SOCIAL SECURITY
ACT
|
42
USC § |
Type |
1. 1128(b)(1)(A)*
|
1320a-7(b)(1)(A) |
Misdemeanor conviction relating
to health care fraud. Minimum Period: 3 years |
2. 1128(b)(1)(B)*
|
1320a-7(b)(1)(B) |
Conviction relating to fraud
in non- health care programs. Minimum Period:
3 |
3. 1128(b)(2) |
1320a-7(b)(2) |
Conviction relating to obstruction
of an investigation. Minimum Period: 3 years |
4. 1128(b)(3)*
|
1320a-7(b)(3) |
Misdemeanor conviction relating
to controlled substance. Minimum Period: 3
years |
5. 1128(b)(4) |
1320a-7(b)(4) |
License revocation or suspension.
Minimum Period: No less than the period imposed
by the state licensing authority. |
6. 1128(b)(5) |
1320a-7(b)(5) |
Exclusion or suspension under
federal or state health care program. Minimum
Period: No less than the period imposed by
federal or state health care program. |
7. 1128(b)(6) |
1320a-7(b)(6) |
Claims for. excessive charges,
unnecessary services or services which fail
to meet professionally recognized standards
of health care, or failure of an HMO to furnish
medically necessary services. Minimum Period:
1 year |
8. 1128(b)(7) |
1320a-7(b)(7) |
Fraud, kickbacks, and other
prohibited activities. Minimum Period: None |
9. 1128(b)(8) |
1320a-7(b)(8) |
Entities controlled by a sanctioned
individual. Minimum Period: Same as length
of individual's exclusion. |
10. 1128(b)(8)(A) ^^
|
1320a-7(b)(8)(A) |
Entities controlled by a family
or household member of an excluded individual
and where there has been a transfer of ownership/
control. Minimum Period: Same as length of
individual's exclusion. |
11. 1128(b)(9), (10), and (11) |
1320a-7(b)(9), (10), and (11)
|
Failure to disclose required
information, supply requested information
on subcontractors and suppliers; or supply
payment information. Minimum Period: None |
12. 1128(b)(12) |
1320a-7(b)(12) |
Failure to grant immediate
access. Minimum Period: None |
13. 1128(b)(13) |
1320a-7(b)(13) |
Failure to take corrective
action. Minimum Period: None |
14. 1128(b)(14) |
1320a-7(b)(14) |
Default on health education
loan or scholarship obligations. Minimum Period:
Until default has been cured or obligations
have been resolved to Public Health Service's
(PHS) satisfaction. |
15. 1128(b)(15)**
|
1320a-7(b)(15) |
Individuals controlling a sanctioned
entity. Minimum Period: Same period as entity. |
16. 1156**
|
1320c-5 |
Failure to meet statutory obligations
of practitioners and providers to provide'
medically necessary services meeting professionally
recognized standards of health care (Peer
Review Organization (PRO) findings). Minimum
Period: 1 year |
NOTE:All exclusions are effective prior
to a hearing except those imposed under
section 1128(b)(7) [42 USC 1320a-7b(b)(7)], and
those imposed on rural physicians under section
1156 [42 USC 1320C-5].
FOOTNOTES:
Health Insurance Portability and Accountability
Act (HIPAA); Public Law 104-191:
Enacted August 21, 1996.
* The effective date of
the new provisions sections 1128(a)(3) and 1128(a)(4),
and the amended provisions section 1128(b)(1)(A),
(B), and section 1128(b)(3) is August 22, 1996.
These provisions apply to offenses occurring on
or after that date.
** The effective date
for the amendments to sections 1128(b)(15), 1128(c)(3),
and 1156 is January 1, 1997.
Balanced Budget Act (BBA); Public Law 105-33:
Enacted August 5, 1997.
^ The effective date for
the amendment to section 1128, and the new provisions
section 1128(c)(3)(G)(i) and (ii) is August
5. 1997.
^^ The effective date
for the amendment to section 1128(b)(8)(A) is
September 19, 1997 (45 days after BBA's
enactment).
NOTE:Check HIPAA and BBA for effective
dates concerning other new amended sections affecting
exclusions.
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