Why Worry About Exclusion

With the rampant and widely publicized episodes of Medicaid and Medicare fraud in recent years, there is increasing pressure on healthcare institutions to perform more frequent sanction screenings of employees and vendors against Federal and State exclusion lists, in order to ensure that they are not billing for the work of excluded parties.

Organizations that are audited and discovered to be billing for services rendered by an excluded vendor or individual will be fined ($11,000 per occurrence) and will be excluded from participating in federally-funded health care programs.

The consequences of employing or contracting with an excluded individual or entity include the following:

  • Reporting and repayment of all monies received by the excluded individual or entity, within 60 days

  • $5,500 to $11,000 fine for EACH item/service claimed or “caused to be” claimed

  • Treble damages, or three times the amount of the program’s loss

  • Extension of the existing exclusion period, or a new exclusion imposed by OIG for the individual/entity

  • Possible criminal false claim situation under FCA (False Claims Act), which is a separate basis for administrative sanctions and exclusions