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Reporting Exclusions from Participation In Federal or State Health Care Programs
Federal agencies, state law enforcement agencies, state Medicaid fraud control units, and state agencies administering or supervising the administration of a state health care program must report health care practitioners, providers, or suppliers excluded from participating in federal or state health care programs. With respect to the reporting of exclusions by the specified state agencies, only the state agency that takes the action to exclude a health care practitioner, provider, or supplier is responsible for reporting that action to the NPDB.
The term "exclusion" means a temporary or permanent debarment of an individual or entity from participation in any federal or state health-related program, such that items or services furnished by the individual or entity will not be reimbursed under any federal or state health-related program. federal health care programs and state health care programs are limited to those defined in the Social Security Act.
The OIG and other federal agencies, state law enforcement agencies, state Medicaid fraud control units, and state agencies administering or supervising the administration of a state health care program also must report any revisions to previously reported exclusions, such as reinstatements, and whether an action is on appeal. For more information, go to Types of Reports in this chapter.
With respect to these types of actions, settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported. However, exclusions that occur in conjunction with settlements in which no finding of liability has been made and that otherwise meet NPDB reporting requirements must be reported.
Table E-19 outlines reporting obligations for exclusions from participation in federal or state health care programs. Table E-20 offers examples of when exclusions should be reported.
| Law | Who Reports? | What is Reported? | Who is Reported? |
|---|---|---|---|
| Title IV | OIG* | Exclusions from participation in Medicare, Medicaid, and other federal health care programs* | Practitioners |
| Section 1921 | State law enforcement agencies** State Medicaid fraud control units** State agencies administering or supervising the administration of a state health care program** |
Exclusions from participation in a state health care program | Practitioners, providers, and suppliers |
| Section 1128E | Federal agencies | Exclusions from participation in a federal health care program | Practitioners, providers, and suppliers |
* This information is reported to the NPDB under Title IV based on a memorandum of understanding.
** NPDB regulations define "state law or fraud enforcement agency" as including but not limited to these entities.
| A practitioner is excluded from a state Medicaid program after pleading guilty to filing false claims. | Yes |
| A company that does not meet the definition of a health care practitioner, provider, or supplier is excluded from a federal health care program. | No |
| A physician is indefinitely excluded from a state Medicaid program because her state medical license was suspended. | Yes |
Sanctions for Failing to Report
If HHS determines that a federal agency, a state law enforcement agency, a state Medicaid fraud control unit, or a state agency administering or supervising the administration of a state health care program has substantially failed to report information required to be reported to the NPDB, the name of the entity will be published and made publicly available.
