decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Exclusion / Permissive Exclusion / Failure of HMOs or other plans to furnish medically necessary services
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Article Overview
This article covers an Office of Inspector General (OIG) permissive exclusion topic involving Medicare and Medicaid managed care organizations that fail to furnish required medically necessary services. It explains the general circumstances under which exclusion may occur, the types of information OIG may consider, the factors that can lengthen or shorten the exclusion period, and an example of how the policy may be applied. The content is relevant to compliance, managed care operations, and health care fraud and abuse professionals who need a high-level understanding of this exclusion authority.
Why This Topic Matters
Managed care organizations and compliance teams need to understand this exclusion authority because failure to provide medically necessary services can trigger significant program consequences. The article highlights the enforcement framework and the kinds of organizational factors that may affect the length of exclusion.
What You Will Learn
- What type of managed care entities are subject to this exclusion authority
- What general information OIG may consider when evaluating exclusion
- What factors may aggravate or mitigate the exclusion period
- How an enforcement example illustrates the policy area
Who Should Read This
- Compliance professionals
- Managed care organizations
- Health care attorneys
- Medical coders and auditors
- Fraud and abuse professionals
Codes Discussed
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