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When Can a Medical Provider Be Excluded by the State or Federal OIG?

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Illinois OIG Exclusion Defense AttorneyIn Illinois, medical providers such as physicians, nurses, medical offices, and hospitals must adhere to strict ethical and legal standards in order to keep their licenses and ensure that they can continue to provide quality care to their patients. There are a variety of situations where state and federal government organizations may investigate a provider based on patient complaints or allegations of abuse or fraud. These investigations are often performed by the Office of Inspector General (OIG), and the state or federal OIG may decide to exclude a medical provider from participating in Medicare, Medicaid, and other federally funded healthcare programs. By understanding the possible reasons for an exclusion, providers who are facing investigations can take the necessary steps to defend their licenses and avoid disciplinary action that could affect their ability to continue practicing.

Federal OIG Exclusions

The federal Office of Inspector General is part of the Department of Health and Human Services (HHS), and it may investigate both individual medical providers and organizations to determine whether they should be excluded from participating in federally-funded healthcare programs. HHS maintains a List of Excluded Individuals/Entities (LEIE), and organizations that hire individuals or work with entities on this list may be subject to civil monetary penalties (CMPs). An individual or entity that is excluded by the OIG cannot receive payments from federal healthcare plans or programs for medical services or products.

There are two types of exclusions that may be put in place by the federal OIG:

  • Mandatory exclusions - The OIG is legally required to exclude any provider that is convicted of Medicare or Medicaid fraud. Convictions for offenses related to patient neglect or abuse, felony convictions for other types of healthcare fraud or financial misconduct, and felony convictions related to drug diversion will also result in mandatory exclusions.

  • Permissive exclusions - The OIG may choose to exclude providers based on issues such as misdemeanor convictions for healthcare fraud (other than Medicare or Medicaid fraud) or fraud involving other government programs. Exclusions may also be imposed in situations involving misdemeanor convictions for controlled substance violations, the suspension or revocation of a person's medical license, claims of substandard or unnecessary treatments to patients, defaulted student loans, or improper financial transactions such as kickbacks.

State OIG Exclusions

At the state level, the Office of Inspector General is part of the Illinois Department of Healthcare and Family Services. It may investigate claims of healthcare fraud or complaints against medical providers, and it may impose sanctions on providers who have committed violations. Providers who are sanctioned are not eligible for Medicaid reimbursement for services provided to patients. Sanctions may be based on issues such as criminal convictions, violations of administrative rules, or accusations of patient neglect or abuse. There are two types of sanctions that may be issued by the Illinois OIG:

  • Termination, barment, and exclusion - This will result in a provider no longer being enrolled in the state's Medical Assistance Program. They will no longer be able to submit claims to Medicaid, and they cannot own or be employed by medical providers that submit claims to Medicaid.

  • Suspension - This is a temporary exclusion from the Medical Assistance Program that will remain in place for a limited period of time. Providers who have been suspended may need to reapply to become Medicaid vendors once their period of suspension is over.

Contact Our Illinois OIG Exclusion Defense Attorney

If you are a medical provider who is being investigated by the state or federal OIG, you will need to determine the steps you can take to defend against exclusion. This is often just one issue that you may need to address if you are facing discipline to your medical license or other penalties. At The Law Offices of Joseph J. Bogdan, Inc., our Illinois medical license defense lawyer can help you determine the best steps you can take in these situations, and we will work closely with you to defend against disciplinary action and protect your license and your livelihood. Contact our office at 630-310-1267 to arrange a free consultation.


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