The Department of Health & Human Services Office of Inspector General (OIG) this morning (October 21, 2010) posted to its website key guidance about when OIG will exercise its authority under the permissive exclusion rules of Social Security Act (Act) § 1128(b)(15)(A)(ii) to exclude from Federal health program participation owners, officers or managing employees of health care organizations based on their role, involvement or ownership interest in a health industry company convicted of certain offenses or excluded from Federal health program participation.

The Guidance For Implementing Permissive Exclusion of Authority under Section 1128(b)(15) of the Social Security Act (Guidance) provides valuable insights for health care organizations, their owners, officers and managers about how OIG expects them to act and the evidence that OIG likely will require should OIG bring an OIG exclusion action against them personally following the conviction or OIG exclusion of their health care organization for misconduct. To position themselves to survive OIG or related exclusion or prosecution, health care organizations and their owners, officers and management use the Guidance as a guide to help strengthen the defensibility of their daily actions against potential OIG scrutiny and consider the advisability of updating their personal and organizational practices, policies and leadership training in response to this Guidance.

The Guidance discusses the guiding principles and core factors and presumptions that OIG generally will apply to decide if the OIG will should exclude an individual from Federal health program participation based on the involvement of the individual as an owner, officer or manager of company that has been excluded from Federal program participation or convicted of certain health care crimes.. Because these OIG has identified these factors as core considerations in its exclusion analysis, the Guidance provides invaluable guidance for health care entities, their owners, officers and management employees about opportunities position their conduct for defensibility against OIG enforcement exposures.  Consequently, owners, officers and managers alike concerned about their exposure to Federal program exclusion or other personal liability under Federal health care fraud laws should use the Guidance to help strengthen their ability to avoid personal exclusion or other prosecution by the OIG as a result of their involvement with a health care organization excluded from Federal program participation or convicted of other crimes.  For a more detailed discussion of the Guidance, see here  

For More Information or Assistance

If you need assistance evaluating or responding to this development of other health care compliance, risk management, transactional, operational, reimbursement, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.

Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Resources

We hope that this information is useful to you.  If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

• CMS Delegated Lead Responsibility For Development of New Affordable Care Act-Required Medicare Self-Referral Disclosure Protocol
• HHS announces Rules Implementing Tools Added By Affordable Care Act to Prevent Federal Health Program Fraud
• HHS announces Rules Implementing Tools Added By Affordable Care Act to Prevent Federal Health Program Fraud
• Monday 9/13 Deadline To Comment Proposed HITECH Act HIPAA Privacy Rules; 9/14 Meeting Studies Proposed Changes
• OIG: Texas Overbilled Medicaid for Medical Transportation Costs
• DMEPOS Suppliers Face 9/27 Deadline To Meet Tightened Medicare Standards
• Initial EHR Certification Bodies Named
• HHS Announces Adjustments to Federal Medical Assistance Percentage (FMAP) Rates
• CMS Publishes Corrections To Proposed 2011 Physician Fee Schedule Rules
• Medicare Changing How It Pays For Outpatient Dialysis
• Last Call: Today Deadline To Comment on Proposed Edits To CMS Nursing Home Civil Monetary Penalty Regs
• Rite Aid Agrees to Pay $1 Million to Settle HIPAA Privacy Case As OCR Moves To Tighten Privacy Rules
• HHS Invites Input On Medicaid Changes To Promote Children’s Health Quality
• CMS Adopts ESRD Facility Prospective Payment System & Proposes New Quality Incentive Program
• CMS Rule Clarifies When Outpatient Services Subject to 3-Day Rule & Finalizes FY 2011 Inpatient Payment Rates
• New Affordable Care Act Mandated High Risk Pre-Existing Condition Insurance Pool Program Regulations Set Program Rules, Prohibit Plan Dumping of High Risk Members
• CMS & ONC To Co-Host 7/22 ONC Certification & Medicare/Medicaid EHR Incentive Program Audio Training
• CMS Proposes Changes To Civil Monetary Penalty Rules For Nursing Homes

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Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review https://slphealthcareupdate.wordpress.com.

You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.

©2010 Cynthia Marcotte Stamer.  Limited license to republish granted to Solutions Law Press.  All other rights reserved.

This entry was posted on Thursday, October 21st, 2010 at 1:21 pm and is filed under ASC, Centers For Disease Control, Childrens Health Insurance Program, Conditions of Participation, Corporate Compliance, Disability Discrimination, DME, Doctor, E-Prescribing, false claims act, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Hospital, Hospital, Indian Health, Medicaid, Medicare, Medicare Advantage, Medicare Fee Schedule, Medicare Fee Schedule, Mental Heatlh, Money Laundering, OIG, Outpatient, Physician, Prescription Drugs, Reimbursement, Rural Health Care, Stark. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.