Dealing with an individual or entity that is excluded from participation in Medicare, Medicaid or another federally funded health care program could result in the imposition of substantial monetary penalties and your own exclusion from federal health care program participation. The Civil Monetary Penalties section of the Social Security Act, as amended by the Balanced Budget Act of 1997, provides that such penalties may be imposed upon any person (including an organization, agency, or other entity) that "arranges or contracts (by employment or otherwise) with an individual or entity that the person knows or should know is excluded from participation in a federal health care program for the provision of items or services for which payment may be made under such program." Potential penalties include:
&#sect; A civil monetary penalty of up to $10,000 for each item or service provided under such an arrangement;
&#sect; An assessment of up to three times the amount claimed for each such item or service in lieu of damages sustained by the federal government or a state agency because of such a claim; and
&#sect; Exclusion of the individual or entity from participation in federal and state health care programs.
The prohibition against "arranging or contracting" with an individual or entity that one knows or should know is excluded from federal health care program participation almost certainly applies to hospitals and other institutional providers who employ or grant clinical privileges to excluded practitioners. Such institutional providers would likely be deemed to know or to be in a position in which they should have known of a practitioner's exclusion status. Hospitals, for instance, are required by federal law to query the National Practitioner Data Bank when hiring or granting clinical privileges to a practitioner, and to perform biannual "follow-up" checks on such practitioners.
Furthermore, the Office of the Inspector General (OIG) has recently made information concerning a practitioner's exclusion status readily accessible through its website www.dhhs.gov/progorg/oig .
If they have not already done so, institutional providers should immediately establish rules and procedures designed to ensure their prompt notification of the proposed or actual exclusion of any practitioner who has or is seeking clinical privileges. Contracts with all providers and suppliers of items or services for which payment may be made under a federal health care program should address contingencies in the event of the provider's or supplier's exclusion from federal health care program participation.
Please contact Connie Baker (410-244-7535, chbaker@venable.com) if you would like further information regarding the potential consequences of dealing with an individual or entity that has been excluded from federal health care program participation. Venable has offices in Maryland, D.C. and Virginia.
&#sect; A civil monetary penalty of up to $10,000 for each item or service provided under such an arrangement;
&#sect; An assessment of up to three times the amount claimed for each such item or service in lieu of damages sustained by the federal government or a state agency because of such a claim; and
&#sect; Exclusion of the individual or entity from participation in federal and state health care programs.
The prohibition against "arranging or contracting" with an individual or entity that one knows or should know is excluded from federal health care program participation almost certainly applies to hospitals and other institutional providers who employ or grant clinical privileges to excluded practitioners. Such institutional providers would likely be deemed to know or to be in a position in which they should have known of a practitioner's exclusion status. Hospitals, for instance, are required by federal law to query the National Practitioner Data Bank when hiring or granting clinical privileges to a practitioner, and to perform biannual "follow-up" checks on such practitioners.
Furthermore, the Office of the Inspector General (OIG) has recently made information concerning a practitioner's exclusion status readily accessible through its website www.dhhs.gov/progorg/oig .
If they have not already done so, institutional providers should immediately establish rules and procedures designed to ensure their prompt notification of the proposed or actual exclusion of any practitioner who has or is seeking clinical privileges. Contracts with all providers and suppliers of items or services for which payment may be made under a federal health care program should address contingencies in the event of the provider's or supplier's exclusion from federal health care program participation.
Please contact Connie Baker (410-244-7535, chbaker@venable.com) if you would like further information regarding the potential consequences of dealing with an individual or entity that has been excluded from federal health care program participation. Venable has offices in Maryland, D.C. and Virginia.