By Robin Brown, Chief Compliance Officer
1-800-778-8130
What Does It Mean If You Are Excluded from Participating in Medicare and Medicaid?
One way the federal Office of Inspector General (OIG) protects the health and well-being of Medicare patients and the Texas OIG protects the health and well-being of Medicaid patients is by excluding individuals and businesses from participating in Medicare and Medicaid. That means individuals or companies on either OIG exclusions list can no longer provide care for and bill services for any Medicare or Medicaid patient. Therefore, excluded individuals or businesses cannot work in healthcare organizations like EHS that accept Medicare or Medicaid.
To protect our Medicare and Medicaid patients here at EHS, we perform exclusion background checks on all employees, vendors, medical staff, agency personnel, and others who work here or provide services for EHS. The exclusion background checks are conducted before working or providing services here and then monthly.
In 2023, the Texas OIG excluded 208 individuals or businesses, and so far in 2024, 155 have been excluded from participation in Medicaid. Likewise, the federal OIG has also excluded hundreds of individuals and businesses. Some of the examples of how individuals or businesses are excluded include:
- Conviction of certain offenses, such as healthcare fraud
- Patient harm in delivering services below the professional standards of care
- Billing for services not medically necessary
- Offering or receiving kickbacks in exchange for business
- Defaulting on a health education student loan or scholarship obligation
The consequences for us allowing anyone excluded to provide services at EHS are severe. Billing Medicare or Medicaid for any services provided by an excluded individual or business could result in paying back any money the hospital receives, termination of our Medicare or Medicaid provider certification, meaning we can no longer bill any Medicare or Medicaid claims, and other significant financial penalties as deemed appropriate by the OIG. We take exclusion background checks seriously and secure the necessary precautions to protect our patients here at EHS.