Q&A: Reporting Exclusions from Federal or State Health Care Programs

4. The OIG pursued civil money penalties and exclusion from Medicare, Medicaid, and other federal health care programs against a physician because of allegations that the physician and his medical practice improperly billed Medicare. The physician appealed the decision to impose a civil money penalty and exclusion to the HHS Departmental Appeals Board. The administrative law judge assigned to the case found in favor of the OIG and upheld the imposition of the civil money penalty and exclusion against the physician. Should these actions be reported as an "other adjudicated action or decision," as an exclusion, or both?

   Both. The civil money penalty should be reported as an "other adjudicated action or decision" because it is a formal or official action taken against a health care practitioner by a federal agency, includes the availability of a due process mechanism, and was based on acts or omissions that affect or could affect the payment of health care services. The exclusion should be reported as an exclusion because the physician was excluded from participation in a federal health care program by a federal agency.