On May 9, 2014, the Office of Inspector General (OIG) of the Department of Health and Human Services released a proposed rule amending regulations regarding OIG’s exclusion authorities. The Affordable Care Act (ACA) expanded OIG’s authority to protect Federal health care programs from fraud and abuse through exclusions. The proposed rule would codify changes adopted in the ACA, provide updates pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act, and make certain other changes to the OIG’s exclusion regulations.  Although the OIG characterizes some of the changes as technical, the proposed rule covers both substantive and procedural issues related to OIG’s mandatory and permissive exclusion authorities.

The proposed rule codifies the OIG’s authority to impose permissive exclusion for:

  • Convictions relating to obstruction of an investigation or audit;
  • Failure to provide payment information, including by individuals who “order, refer for furnishing, or certify the need for” items or services paid for by Medicare or State health care programs; and
  • Making false statements or misrepresenting materials facts in applications to participate as a provider or supplier under a Federal health care program.

Other proposed changes include proposing early reinstatement rules for individuals excluded as a result of losing their licenses, the mandatory exclusion waiver provision, amendments of mitigating and aggravating factors, and other administrative process changes.