Posted by: Robert Markette
August 11, 2006

I recently read a letter regarding Medicare and Medicaid fraud that stated the government was looking to enforce the Medicare exclusion list more stringently. This means they are looking for individuals who are excluded who might be providing services.

As you should know, there are a number of reasons an individual may be excluded from participation in the Medicare program. Once they are excluded, they are essentially unemployable by any provider that receives reimbursement from a federal health care program.

In other words, if you provide Medicare, Medicaid, Medicaid waiver services or services through another federal insurance program, you cannot employ excluded individuals. (At least that is OIGs opinion and the fine points of that opinion are beyond the scope of this post.) Although there are ways that a Medicare or other provider could structure things to avoid this problem, it is far simpler to just not employ excluded individuals.

This means that before you hire someone, you should be sure to check the exclusion lists. You can view this list at exlusions list page . When you are checking, be sure to check any maiden names or other names of which you may be aware.

Some of you may be asking, what if we did employ someone who was excluded. If you have, there are a number of potential penalties. First, the government could recover payment for any claims paid for which the excluded person provided services. Second, the government could pursue civil monetary penalties against you. If the government can prove you knew or should have known the individual was excluded, they can recover penalties of $10,000 per claim submitted.

This can become quite expensive for a provider. One way to avoid this is prevention. For example, OIG recommends that an employment application ask the potential new employee to disclose not only criminal convictions, but if they have been subjected to an exclusion action. They also recommend taking action if current employees are subjected to an exclusion action during employment. (Of course check your personnel policies to be sure you take the appropriate action.)They real point here is that Medicaid fraud units may be looking more closely at this issue and you should be sure to ensure you do not hire an excluded individual.

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