April 16, 2023

Notice of Exclusions From Medicare Benefits

notice of exclusions from medicare benefits

The OIG can exclude individuals and entities from Medicare, Medicaid, or any other Federal health program based on various violations of the Social Security Act (the Act) or federal health law. The exclusions are not permanent, but do prevent individuals and entities from participating as providers under these programs.

NOI - A Notice of Intent to Exclude:

After receipt of the OIG's proposed exclusion, providers and entities have 30 days to provide written responses and submit any relevant information or evidence to the OIG. This is important because the OIG must consider any material provided in response when making its determinations.

Written Responses are typically very thorough, and may focus on whether the proposed exclusion is warranted. In addition, they can raise mitigating factors that should be addressed before a final decision is made.

Advance Beneficiary Notices:

The Office of Management and Budget (OMB) has approved these notices for items and services provided under Part B, including hospital outpatient services and certain care provided under Part A (hospice and religious non-medical healthcare institutes only [RNHCI]). Skilled nursing facilities should also issue them for Part B services.

Preservice OD:

If an excluded person is planning to receive medically necessary services, it's a good idea for the member to obtain an OD before receiving the service. This helps the member to understand if they have coverage for the service, and ensures that they aren't held financially liable for any noncovered services.

The Centers for Medicare & Medicaid Services (CMS) has the authority to exclude individuals and entities from Federally funded health care programs pursuant to section 1128 of the Social Security Act and maintains a list of excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an excluded person or entity on the LEIE may be subject to civil monetary penalties (CMPs). To avoid CMP liability, health care entities must routinely check the LEIE.


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