decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Exclusion / Permissive Exclusion / Fraud, kickbacks and other prohibited activities
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Article Overview
This premium article covers exclusion policy tied to fraud, kickbacks, and other prohibited activities under federal healthcare program rules. It is aimed at coders, compliance staff, auditors, and healthcare administrators who need a high-level understanding of OIG exclusion considerations, mitigating factors, and the categories of safe harbor protection referenced in the discussion. The article also provides context for why these issues matter across Medicare and Medicaid participation and related enforcement actions.
Why This Topic Matters
Exclusion can affect a provider’s ability to participate in federal healthcare programs, making fraud- and kickback-related compliance a critical operational and revenue-cycle issue. Understanding the broad enforcement framework helps readers recognize when legal and compliance review is needed.
Article Sections
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OIG exclusion and illegal remuneration
Introduces exclusion authority related to prohibited remuneration and discusses the broad factors considered in assessing the seriousness of misconduct.
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Length of exclusion
Summarizes the general considerations used in determining how long exclusion may last and the kinds of circumstances reviewed.
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Mitigating factors
Reviews circumstances that may reduce culpability or affect sanctions in exclusion-related cases.
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Exceptions
Describes the existence of OIG safe harbor exceptions and identifies the major categories referenced in the article.
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Example
Provides an illustrative scenario involving referrals, alleged prohibited remuneration, and resulting enforcement consequences.
What You Will Learn
- How exclusion relates to prohibited remuneration and enforcement under federal healthcare program rules.
- What broad factors may be considered when exclusion length is evaluated.
- Which general mitigating circumstances are referenced in connection with sanctions.
- How OIG safe harbor concepts function as exceptions in this topic area.
- What kinds of compliance issues can arise in a referral-based example involving provider relationships.
Who Should Read This
- Medical coders
- Compliance officers
- Healthcare administrators
- Auditors
- Revenue cycle professionals
- Risk management staff
Codes Discussed
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