DecisionHealth, DecisionHealth - 2004 Issue 2 (February)
Excluded physicians
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Article Overview
This article discusses the compliance implications of billing when a referring or requesting physician has been excluded from federal health care programs. It is aimed at surgeons, coders, billing staff, and practice administrators who need to understand how exclusion status can affect consults, ordered services, and claim handling. The article also references the role of the OIG, CMS, and the LEIE database as part of the broader exclusion-check process.
Why This Topic Matters
Exclusion status can affect whether services are payable and whether claims may be denied or require corrective action. The topic is important for practices that receive referrals, order tests, hire clinicians, or manage Medicare and Medicaid billing compliance.
What You Will Learn
- Why provider exclusion status matters for referral-based billing
- How exclusion screening fits into billing and compliance workflows
- Which organizations maintain and enforce federal exclusion information
- What general situations may trigger the need to verify a provider’s status
Who Should Read This
- Surgeons
- Medical coders
- Billing staff
- Practice managers
- Compliance personnel
- Health care administrators
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