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IL license defense lawyerAround 28% of all health care services in the United States are paid for through Medicare, Medicaid, or other federal programs. Because of this, health care providers need to comply with all applicable requirements, since being unable to provide services through these programs can eliminate a major source of revenue. The Office of Inspector General (OIG) for the federal Department of Health and Human Services (HHS) maintains a List of Excluded Individuals/Entities (LEIE), and any providers or organizations that are included on this list cannot receive payments from federal healthcare programs. Medical providers will want to understand the issues that could cause them to be included on this list and the actions they can take to prevent exclusion from Medicare or Medicaid programs.

Reasons for Exclusion

In many cases, a provider may face exclusion by the OIG due to charges of health care fraud or other offenses. The OIG has the discretion to issue a permissive exclusion if a provider is convicted of misdemeanor health care fraud or a misdemeanor related to illegal prescribing or dispensing of controlled substances or if their medical license has been suspended or revoked. Felony convictions for healthcare fraud or controlled substances, convictions related to abuse or neglect of patients, or any convictions for fraud against Medicare or Medicaid will result in a mandatory exclusion.

Effects of Being on the OIG Exclusion List

A provider who is on the LEIE will be barred from receiving payments for services through federal programs. If an excluded person submits a claim for payment through a federal program, they may face a civil monetary penalty (CMP) of up to $10,000 for each service furnished. In addition, an organization that employs or contracts with an excluded person may face a CMP if any services provided by the person were payable through Medicare or Medicaid. These services may include direct or indirect patient care, administrative services, or other prescriptions, items, or services provided at the direction of the excluded person. Because of these penalties, many hospitals and medical offices will not hire or contract with a service that employs a person who is on the LEIE.


IL license defense lawyerFor healthcare providers such as doctors, nurses, psychologists, physical therapists, or pharmacists, notification that their practice is being investigated by an Office of Inspector General (OIG) can be very concerning. A state or federal OIG will look into reports of healthcare fraud or forms of waste or mismanagement involving Medicare or Medicaid. Depending on the results of an investigation, a provider may face a number of consequences, including exclusion from these programs or even criminal charges. To avoid these issues, it is crucial for providers to secure representation from an experienced attorney as soon as they are aware of an OIG investigation.

What Is the Office of Inspector General?

Different departments of the federal government and state governments have their own Offices of Inspector General. These offices are tasked with uncovering fraud, waste, or abuse that results in financial losses for government programs. Since Medicare is a federal program, the Office of Inspector General for the federal Department of Health and Human Services will investigate cases related to this program. Medicaid is administered at the state level, so the applicable state Office of Inspector General will usually investigate allegations of fraud or waste involving this program.

What Happens During an OIG Investigation?

In most cases, an OIG will investigate claims that a provider has committed healthcare fraud, which may include:


IL medical license defense lawyerAccording to the Centers for Medicare & Medicaid Services (CMS), there are currently more than 60 million Americans who are enrolled as Medicare beneficiaries. This number includes individuals enrolled in “original” Medicare as well as in Medicare Advantage plans with private insurers. In order to be able to serve this large portion of the population, a medical provider must enroll as a Medicare provider and keep that enrollment in good standing. This means the provider must meet all of the requirements set forth by CMS and avoid behaviors that could lead to a revocation of the provider’s Medicare status.

Revocation of Medicare Enrollment

Under §424.535 of the Code of Federal Regulations, there are many different reasons for which a provider could have his or her Medicare enrollment status revoked. They include noncompliance with enrollment requirements, causing harm to patients, being convicted of certain felonies, improper medication prescribing practices, and failing to comply with CMS reporting requirements, among many others.

As a provider, you could also lose your Medicare enrollment status for abusing your billing privileges. Under the law, abuse of billing privileges includes but is not limited to:


IL defense lawyerThe global pandemic COVID-19 has hit the U.S. especially hard, with over 199,000 confirmed cases in Illinois alone. From the beginning, this virus has led to overfilled hospital beds and overworked medical professionals. With no vaccination in sight and a high demand for doctors, nurses, and other medical professionals, the U.S. has been forced to reevaluate their licensing procedures and state-by-state restrictions. It is common for states to adopt emergency licensing processes in response to natural disasters and their aftermath. Many states have followed this trend by enacting emergency-response licensure laws to allow volunteers from other states to practice their profession without being required to seek out licensure in that specific state.

Uniform Emergency Volunteer Health Practitioner Act

The Uniform Emergency Volunteer Health Practitioner Act (UEVHPA) is legislation that was initially developed in 2006 and is being modeled by many states during the COVID-19 pandemic. This legislation allows any participating state, Illinois included, to recognize out-of-state medical licenses during a declared state emergency. All practitioners who wish to participate in this reciprocal-licensing program must register to do so.

Illinois-Specific Legislation

Aside from the UEVHPA, which has been adopted by most states during this time, Illinois has enacted a few regulations of its own. Under Gov. Pritzker’s direction, the Illinois Department of Financial and Professional Regulation is allowing healthcare workers whose licenses have recently expired to temporarily restore their licenses to assist with COVID-19 patients. Physician assistants and doctors who have expired or inactive licenses from less than three years ago are able to return to work without paying any required licensing fees or making further progress on their education requirements. Additional leeway has been given to nurses and respiratory therapists, giving them a five-year pass rather than the three-year allotment given to doctors and physician assistants.

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