If your practice is under investigation by the OIG, there’s a chance you may face penalties and sanctions for whatever wrongdoing the feds find. For some providers, this may mean facing the threat of exclusion from the Medicare program, or entering into a corporate integrity agreement (CIA). You’ll need to have an attorney well-versed in both of these options to help advise you along the way, but in the meantime, it’s a good idea to familiarize yourself with what each option entails.
Check out several key facts about Medicare exclusion vs. a corporate integrity agreement so you can be ready if you ever need to choose between the two.
In Some Cases, Exclusion Is Mandatory
Medicare exclusion means that the provider or supplier is no longer able to participate in any healthcare programs that are funded by the US government, including Medicare, Medicaid, SCHIP and Tricare. Exclusion is widely considered to be among the most serious punishments that a provider can face. Other serious penalties include prison time and financial penalties.
There are situations when the OIG can decide whether or not to exclude a provider from continued participation in the Medicare or Medicaid program, but in other cases, exclusion is mandatory. For example, providers who commit Medicare fraud, those who abuse patients and individuals who are convicted of felonies related to unlawful distribution of medications are typically automatically excluded from Medicare.
In other cases, however, the OIG can choose to exclude providers under its “permissive exclusion” program. If you commit an offense that falls under the permissive exclusion category, you may have more negotiating power to try and avoid being excluded. One such option would be to enter into a CIA with the government so you can avoid exclusion.
Corporate Integrity Agreement (CIA) May Be an Option
If you’re working with a lawyer and the OIG to determine whether you’ll face exclusion or a CIA, your lawyer is likely to advise you to instead opt for the CIA.
Here’s why: Under a corporate integrity agreement, you’ll agree to certain obligations and requirements. In exchange, the government will not exclude you from federal healthcare program participation. This allows you to continue collecting from Medicare and Medicaid as you work to demonstrate to the OIG that your compliance issues are behind you and that you’re operating compliantly going forward.
CIAs typically last for five years. According to the OIG, the terms of the CIA will require you to implement the following steps to ensure you stay on the straight and narrow going forward:
- Develop written policies and standards
- Hire a compliance officer and/or appoint a compliance committee
- Create a confidential disclosure program
- Retain an independent review organization to perform annual reviews
- Restrict employment of ineligible individuals
- Create a confidential disclosure program
- Report overpayments, legal proceeding and any ongoing investigations to the government
- Provide an implementation report and annual updates to the OIG on your compliance activities
Know the OIG’s Criteria
The OIG will use a comprehensive set of criteria when evaluating whether you’re eligible for a CIA rather than an exclusion, but it’s never a guarantee. You should go over the criteria with your attorney. Together, you can calculate the odds of being able to qualify for a CIA rather than an exclusion.
Want to know more about how to stay compliant at your medical practice? Sign up for one of Training Leaders’ comprehensive online training events. In only an hour of your time, you’ll find out how to stay on the straight and narrow to avoid OIG and RAC scrutiny. Find out more!
 |
Subscribe to Healthcare Practice Advisor |
| Get actionable advice to help improve your practice’s reimbursement, compliance, and success in this weekly eNewsletter. |
|
|
|