Exclusion Authorities
Scope
Social Security Act |
42 USC § |
Amendment |
1128 |
1320a-7 |
Scope of exclusions imposed by OIG expanded from Medicare and State health care programs to all Federal health care programs, as defined in section 1128B (f)(1). |
Mandatory Exclusions
Social Security Act |
42 USC § |
Amendment |
1128(a)(1) |
1320a-7(a)(1) |
Conviction of program-related crimes. Minimum Period: 5 years |
1128(a)(2) |
1320a-7(a)(2) |
Conviction relating to patient abuse or neglect. Minimum Period: 5 years |
1128(a)(3) |
1320a-7(a)(3) |
Felony conviction relating to health care fraud. Minimum Period: 5 years |
1128(a)(4) |
1320a-7(a)(4) |
Felony conviction relating to controlled substance. Minimum Period: 5 years |
1128(c)(3)(G)(i) |
1320a-7(c)(3)(G)(i) |
Conviction of second mandatory exclusion offense. Minimum Period: 10 years |
1128(c)(3)(G)(ii) |
1320a-7(c)(3)(G)(ii) |
Conviction of third or more mandatory exclusion offenses. Permanent Exclusion |
Permissive Exclusions
Social Security Act |
42 USC § |
Amendment |
1128(b)(1)(A) |
1320a-7(b)(1)(A) |
Misdemeanor conviction relating to health care fraud. Baseline Period: 3 years |
1128(b)(1)(B) |
1320a-7(b)(1)(B) |
Conviction relating to fraud in non-health care programs. Baseline Period: 3 years |
1128(b)(2) |
1320a-7(b)(2) |
Conviction relating to obstruction of an investigation or audit.
End of Translation
Baseline Period: 3 years |
1128(b)(3) |
1320a-7(b)(3) |
Misdemeanor conviction relating to controlled substance. Baseline Period: 3 years |
1128(b)(4) |
1320a-7(b)(4) |
License revocation, suspension, or surrender. Minimum Period: Period imposed by the state licensing authority. |
1128(b)(5) |
1320a-7(b)(5) |
Exclusion or suspension under federal or state health care program. Minimum Period: No less than the period imposed by federal or state health care program. |
1128(b)(6) |
1320a-7(b)(6) |
Claims for excessive charges, unnecessary services or services which fail to meet professionally recognized standards of health care, or failure of an HMO to furnish medically necessary services. Minimum Period: 1 year |
1128(b)(7) |
1320a-7(b)(7) |
Fraud, kickbacks, and other prohibited activities. Minimum Period: None |
1128(b)(8) |
1320a-7(b)(8) |
Entities controlled by a sanctioned individual. Minimum Period: Same as length of individual's exclusion. |
1128(b)(8)(A) |
1320a-7(b)(8)(A) |
Entities controlled by a family or household member of an excluded individual and where there has been a transfer of ownership/control. Minimum Period: Same as length of individual's exclusion. |
1128(b)(9), (10), and (11) |
1320a-7(b)(9), (10), and (11) |
Failure to disclose required information, supply requested information on subcontractors and suppliers; or supply payment information. Minimum Period: None |
1128(b)(12) |
1320a-7(b)(12) |
Failure to grant immediate access. Minimum Period: None |
1128(b)(13) |
1320a-7(b)(13) |
Failure to take corrective action. Minimum Period: None |
1128(b)(14) |
1320a-7(b)(14) |
Default on health education loan or scholarship obligations. Minimum Period: Until default or obligation has been resolved. |
1128(b)(15) |
1320a-7(b)(15) |
Individuals controlling a sanctioned entity. Minimum Period: Same as length of entity's exclusion. |
1128(b)(16) |
1320a-7(b)(16) |
Making false statement or misrepresentations of material fact. Minimum period: None. |
1156 |
1320c-5 |
Failure to meet statutory obligations of practitioners and providers to provide medically necessary services meeting professionally recognized standards of health care (Quality Improvement Organization (QIO) findings). Minimum Period: 1 year |
Note: except those imposed under section 1128(b)(7) (42 USC 1320a-7b(b)(7)), and those imposed on rural physicians under section 1156 (42 USC 1320C-5), all exclusions are effective prior to a hearing.