Medicare_Carriers_Manual / 14030 / 14030.3_DEVELOPMENT_OF_POTENTIAL_EXCLUSION_CASES.

Why This Topic Matters

It helps program integrity staff understand what information to gather and how to frame a potential exclusion referral so it can be evaluated consistently and supported by documentation.

Article Sections

1. A. Case Considerations

   Discusses the broad factors considered when recommending cases for exclusion review, including seriousness, deterrence, community impact, and documentation expectations when no conviction is present.

2. B. Notification to Provider

   Covers the provider notification process after potential fraud or abuse is identified, including required content, documentation of communication, and escalation of strong fraud or harmful care situations.

3. C. Additional Information

   Identifies additional categories of supporting information that may strengthen a proposal to exclude, such as program impact and potential savings.

4. D. Mitigating Circumstances

   Describes the role of factors that may reduce the seriousness of the issue and should be shared with OI when a sanction recommendation is forwarded.