HOW DOES AN EXCLUDED PARTY GET REINSTATED TO PARTICIPATE IN THE FEDERAL HEALTH CARE PROGAMS?

| Posted on |

May 4, 2023

The Office of Inspector General (OIG) addresses reinstatement to participate in Federal healthcare programs after an individual or entity’s state license has been revoked, suspended or surrendered here: (https://www.oig.hhs.gov/exclusions/reinstatement.asp)

Individuals or entities who have been excluded from participating in Federal healthcare programs can apply to be reinstated upon:

  1. Completion of their defined exclusion period – they can start the application process 90-days before the end of the exclusion period
  2. Regaining licensure that was excluded

Early reinstatement will be considered by OIG if the excluded party obtains a new health care license from a different State, or a different health care license from the same State, or the licensing authority decides to take no adverse action against the currently held health care license.  Also, if an excluded party does not have a valid health care license in any state and has been excluded for a minimum of 3 years, the OIG will consider early reinstatement.  There are several factors that the OIG will consider when determining early reinstatement.  These factors can be found at 42 CFR § 1001.501(c)(1) and § 1001.501(c)(2).

Applications for early reinstatement, without regaining the license that was excluded, are also available in limited instances by:

  1. Obtaining a different health care license in the same state or
  2. Obtaining any healthcare license in a different state

NOTE: Early reinstatement is not available if the license was revoked, suspended, or lost due to reasons relating to patient abuse or neglect

The exclusion period will not be shorter than the time the state license has been revoked, suspended or made ineffective by the state.  However, the exclusion period may be extended past the state licensing action if:

  1. The reason for the license being revoked, suspended, or lost had/could have had a “significant adverse physical, emotional or financial impact” on a beneficiary
  2. The excluded party “has a documented history of criminal, civil or administrative wrongdoing”
  3. The reason for license revocation “had or could have had a significant adverse impact on the financial integrity of the (Federal health care) programs” or
  4. The excluded party is involved in some other adverse action related to the reason for exclusion

The extended exclusion period, for reasons based on items 1 – 4 above, may be reduced if the excluded party’s cooperation with the State licensing authority resulted in:

  1. The sanctioning of other parties
  2. Other cases of program vulnerabilities or weaknesses are being investigated

More information can be found at https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1001/subpart-C/section-1001.501

If the OIG approves the request for reinstatement, they issue a notification with reinstatement date to the following:

  1. Excluded party
  2. CMS
  3. Other State and Federal health care programs
  4. Any others who were a part of the original exclusion notice

However, if other Federal health care programs issued an exclusion under their own authority, the OIG’s reinstatement has no effect on the other Programs exclusion decisions.

In the event the request for reinstatement is denied, the OIG will send a written notice to the excluded party.  The excluded party has 30-days to appeal the denial and submit additional evidence to support the request for reinstatement:

  1. “Documentary evidence and written argument against the continued exclusion,
  2. A written request to present written evidence and oral argument to an OIGofficial, or
  3. Both documentary evidence and a written request.”

If evidence has been submitted within the 30-day period, the OIG will review the evidence and determine if they will uphold the denial or approve the request for reinstatement.  If the denial is upheld, the excluded party will not be able to submit a subsequent request for reinstatement until at least one year after the date of denial.

Upon appeal, if the decision/conviction is reversed or vacated (e.g., by the OIG, a State agency, or licensing board), the exclusion will be withdrawn, and the individual/entity will be retroactively (to the effective date of the exclusion) reinstated.  CMS will make any payments for covered services provided during the exclusion period.  The exclusion reversal made by the OIG does not affect exclusion decisions made by other Federal health care programs.

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