Medicare Compliance & Reimbursement

Question: When an individual is excluded from participating in the Medicare program by the HHS Office of Inspector General (OIG), what is the process for reinstatement?

Maryland Subscriber

Answer: To be blunt — it’s complicated and it’s based on the parameters of the individual’s exclusion from Medicare and other federal programs.

First: You should understand that when a provider is excluded by OIG from federal healthcare programs that it is essentially a ban on payment for services and items rendered to patients. “This payment ban applies to all methods of Federal program reimbursement, whether payment results from itemized claims, cost reports, fee schedules or a prospective payment system (PPS),” OIG says in online guidance.

Furthermore, the payment ban also includes reimbursement for administrative and management fees that are related to federal healthcare program beneficiaries, and thus fall under the payment rules. And “this prohibition continues to apply to an individual even if he or she changes from one health care profession to another while excluded,” OIG warns. “In addition, no Federal program payment may be made to cover an excluded individual’s salary, expenses or fringe benefits, regardless of whether they provide direct patient care.”

Next: Know that reinstatement isn’t automatic when the period of exclusion ends. “The individual or entity must apply for reinstatement and receive written notice from OIG that reinstatement has been granted,” OIG notes in an FAQ on exclusions.

If an individual’s exclusion has an established timeline, then the provider can start “the process of reinstatement 90 days before the end of the period specified in the exclusion notice letter,” OIG says. Submitting a reinstatement request before the allotted time will automatically be denied.

For those individuals with no determined dates of exclusion, other factors may apply from obtaining new medical licensure, re-enrolling and getting a new provider number, state laws, and more.

Review the OIG advisory on exclusions and the OIG FAQs.