About Texas HHSC OIG Exclusion Program
Texas Health & Human services Commission (Commission), Office of Inspector General (OIG) works diligently to protect the health and welfare of the Texas Medicaid’s and other HHS program’s recipients by preventing certain individuals and businesses from participating in health care programs. The OIG excludes individuals and entities affected by various legal authorities. A listing of all currently excluded parties is maintained by OIG and is called the List of Excluded Individuals/Entities by Texas OIG.
Bases for exclusion include convictions for program-related fraud and patient abuse, licensing board actions, U.S. Health & Human Services OIG (Medicare) exclusion actions, and “Permissive” exclusions as allowed by various legal authorities.
It is each provider’s or person’s responsibility to ensure that items or services furnished personally by, at the medical direction of, or on the prescription or order of an excluded person are not billed to the Titles V (Maternal and Child Health Services), XIX (Medicaid), XX (Block Grants for Social Services), and/or other HHS programs after the effective date of exclusion. This section applies regardless of whether an excluded person has obtained a program provider number or equivalent, either as an individual or as a member of a group, prior to being reinstated.
Failure to ensure excluded providers are not participating in the activities above and/or billing for services rendered by an excluded person will result in exclusion of the currently active providers and persons allowing the forbidden activity, plus recoupment of all funds paid to the currently active provider or person for those activities, and imposition of damages and penalties against both the currently active provider or person and the excluded person. The damages and penalties are delineated in 1 TAC §371.1721 et seq. of this subchapter.1
The effect of exclusion2
from Medicaid, Title V, and Title XX and other HHS programs is as follows:
• No payment will be made by these programs for any item or service furnished by the exclude person on or after the effective date of exclusion;
• The excluded person must neither personally nor through a clinic, group, corporation, or other association or entity, bill or otherwise request or receive payment for any Title V, XIX, or XX, or other HHS programs for items or services provided on or after the effective date of the exclusion. Exclusion also prevents the excluded person from providing any services pursuant to the Medicaid program, whether or not you directly request Medicaid program payment for such services;
• The excluded person must not assess care or order or prescribe services, directly or indirectly, to Title V, XIX, or XX, or other HHS programs recipients after the effective date of exclusion. A clinic, group, corporation, or other association or entity must not submit claims for any assessments, services or items provided by a person within such organization or entity who is excluded from participation, unless the services or supplies were provided before the effective date of exclusion;
• An entity that employs or otherwise associates with a person excluded from participation in Titles V, XIX, or XX, other HHS programs must not include within a cost report or any documents used to determine an individual payment rate, a statewide payment rate or a fee, the salary, fringe benefits, overhead, or any other costs associated with the person excluded;
• An order or prescription written before the exclusion effective date is valid for the duration of the order or prescription; and
• An order or prescription written before the exclusion effective date is valid
for the duration of the order or prescription; and
• If, after the effective date of an exclusion, claims are submitted or are cause to be submitted for services or items furnished within the period of exclusion, administrative damages and/or penalties may be imposed.3
1See 1 Texas Administrative Code (TAC) §371.1677(a)
2See 1 TAC §371.1673 “Scope and Effect of Exclusion”
3See Social Security Act §§ 1128(a)(1)(D), 1128B(a)(3), 1 TAC §§ 371.1721-371.1741, and Texas Human Resources
Code § 32.039