James I. Glasser

Billing Federal Health Care Programs for Excluded Individuals and Entities is a Government Enforcement Priority

March 11, 2009 Advisory

At a recent Health Care Roundtable sponsored by Wiggin and Dana LLP, Assistant United States Attorney Richard M. Molot advised attendees that "exclusion billing" is now a government enforcement priority. Exclusion billing is the unlawful practice of billing Medicare, Medicaid, and other federal health care programs for services provided by individuals or entities, including employees or contractors, that are excluded from participation in federal health care programs.
The Balanced Budget Act of 1997 authorized the OIG to impose civil monetary penalties on anyone that employs or contracts with excluded individuals or entities to provide services or supplies that are reimbursed by federal health care programs. Peanlties for exclusion billing can include fines of up to $10,000 for each billed item or service furnished by the excluded individual or entity, recoupment of reimbursement recived for such services, civil monetary penalties of up to three times the amount of the claims submitted, and program exclusion. AUSA Molot announced that there has been an uptick in such investigations, many of which are brought to the government's attention by whistleblowers.
This advisory explains the legal requirements pertaining to exclusion and discusses recent examples of government investigations and civil settlements. Finally, it presents practical tips for avoiding compliance problems.