CMS Pub. 100-08, ch. 4, § 4.10.2

Services

(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21)

Section 1128 of the Act provides the Secretary of DHHS the authority to exclude various

health care providers, individuals, and businesses from receiving payment for services

that would otherwise be payable under Medicare, Medicaid, and all federal health care

programs. This authority has been delegated to the OIG.

When an exclusion is imposed, no payment is made to anyone for any items or services

in any capacity (other than an emergency item or service provided by an individual who

does not routinely provide emergency health care items or services) furnished, ordered,

or prescribed by an excluded party under the Medicare, Medicaid, and all federal health

care programs. In addition, no payment is made to any business or facility, e.g., a

hospital, that submits claims for payment of items or services provided, ordered,

prescribed, or referred by an excluded party.

The OIG also has the authority under §1128(b)(6) of the Act to exclude from coverage

items and services furnished by practitioners, providers, or other suppliers of health care

services who have engaged in certain forms of program abuse and quality of care issues.

In order to prove such cases, the UPICs shall document a long-standing pattern of care in

which educational efforts have failed to change the abusive pattern. Isolated instances

and statistical samples are not actionable. Medical doctors must be willing to testify.

Authority under §1156 of the Act is delegated to OIG to exclude practitioners and other

persons who have been determined by a QIO to have violated their obligations under

§1156 of the Act. To exclude, the violation of obligation under §1156 of the Act must be

a substantial violation in a substantial number of cases or a gross and flagrant violation

in one or more instances. Payment is not made for items and services furnished by an

excluded practitioner or other person. Section 1156 of the Act also contains the authority

to impose a monetary penalty in lieu of exclusion. Section 1156 exclusion actions and

monetary penalties are submitted by QIOs to the OIG/OI.

Payment is not made for items and services furnished by an excluded practitioner or

other person.