Referrals for Exclusion Based on Convictions

Exclusion Authority

OIG is required to exclude individuals and entities convicted of the following types of criminal offenses:

• Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid, CHIP, or other State health care programs;
• Offenses related to patient abuse or neglect in connection with the delivery of health care items or services;
• Felony offenses for fraud, theft, embezzlement, breach of fiduciary duty, or other financial misconduct committed in connection with the delivery of a health care item or service or involving other government health care programs; and
• Felony offenses related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances by an individual or entity involved in the health care industry.

OIG has discretion to exclude individuals and entities on several grounds, including:

• Misdemeanor convictions for health care related fraud, theft, embezzlement, breach of fiduciary duty, or other financial misconduct;
• Misdemeanor convictions related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances by a health care related individual or entity.

For purposes of exclusion, an individual is considered "convicted" when:

• Judgment of conviction has been entered by a Federal, State or local court, regardless of whether an appeal or post-trial motion is pending, or the record has been expunged or otherwise removed;
• Federal, State or local court has made a finding of guilt;
• Federal, State or local court has accepted a plea of guilty or nolo contendere; or
• The individual has entered into a first offender, deferred adjudication, or other program where judgment of conviction has been withheld.

How to Make an Exclusion Referral

If you become aware of a conviction that might serve as a basis for an exclusion, please let us know. At a minimum, OIG needs the following information to begin an exclusion investigation. If the documents set forth below are available, please send the OIG copies:

Information

• Defendant's name
• Name of the court in which the Defendant was convicted and the Docket or Case Number
• The crimes for which the Defendant was convicted and the date of the conviction and/or sentence
• Referring agency point of contact, should OIG need additional information

Documentation

• Judgment and sentence order
• Plea agreement (if applicable)
• All charging documents (i.e., indictment, complaint or information)
• Any document that amends any of the above
• Investigative reports, police reports, or factual summary

If the document contains Personally Identifiable Information (PII) or Protected Health care Information (PHI), please contact the OIG to arrange to use the OIG's secure server to transmit the documents rather than sending them by e-mail.