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Q&A: Reporting Exclusions from Federal or State Health Care Programs
The OIG pursued civil money penalties and exclusion against a physician because the physician and his medical practice allegedly billed Medicare improperly. The physician and his medical practice agreed to settle the case. The settlement did not include findings or admissions of liability, but the physician agreed to pay $100,000 for allegedly violating the Civil Money Penalties Law and agreed to be excluded from Medicare, Medicaid, and other federal health care programs for 3 years. Should the civil money penalty or the exclusion, or both, be reported to the NPDB?
The payment should not be reported because it was part of a settlement in which no findings or admissions of liability were made. Section 1128E specifically excludes from NPDB reporting any settlement that does not include an admission of liability. However, the exclusion must be reported. 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.
If the settlement had included an admission of liability, it would have been reportable under 45 CFR § 60.16 as an "other adjudicated action or decision." As defined in NPDB regulations, the settlement would have been a "formal or official final action[]" that "include[d] the availability of a due process mechanism" and was "based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service."
