What is an Exclusion Waiver and Who May Apply

exclusion waiver

We have previously discussed that once a provider is excluded he may not furnish items or services paid for by the the Federal health care programs until he is eligible to apply for reinstatement and the Office of the Inspector General (OIG) approves this reinstatement request. The one exception to this general rule is that OIG does have the authority to grant certain excluded individuals or entities an exclusion waiver.1 

I.  What is an Exclusion Waiver?

Waivers permit certain excluded individuals or entities to be eligible for payment by Medicare, Medicaid, and all other Federal health care programs for specific items and services defined in the scope of the waiver.

A waiver will explicitly define the scope of services an excluded individual or entity may provide. It may permit payment under the Federal health care programs for covered services like office visits, home visits, and hospital visits. It may also permit hospital stays, medical tests, procedures, and/or equipment ordered by the provider, and drugs, devices, and/or other items prescribed by the provider.

II.  Who may apply?

Waivers are only available for excluded providers that are the only physician or source of an essential specialized service within a specific geographic location or institution. 

A waiver will not and cannot be granted to a person excluded due to patient neglect or abuse.

III.  How may a provider request an exclusion waiver?

A waiver may only be requested by the administrator of a Federal or state health care program.

IV.  What payment is provided under an exclusion waiver?

When a waiver is granted, payment by Medicare, Medicaid, and all other Federal health care programs is permitted for items and services that are outlined under the scope of the waiver. The waiver may limit care to a specific geographic region or to a medical specialty.

V.  What does this mean for an excluded provider?

This means that a waiver is not a viable way for an excluded provider to participate in the Federal health care programs while he waits until he is eligible to apply for reinstatement. There are currently only 18 waivers in effect. The states with the most providers practicing pursuant to an effective waiver are New Mexico (4), Montana (2), and Arkansas (2). 

VI. Conclusion

Providers are reminded that they may be excluded from participation in the Federal health care programs for employing or contracting with an excluded individual or entity. If you are excluded from participation you will likely not be eligible to participate under a waiver, and will therefore have to wait out your exclusion period to apply for reinstatement. Instead of taking these chances, contact Exclusion Screening, LLCSM today to discuss your Exclusion Screening needs at 1-800-294-0952 or online for a free consultation.

 Ashley Hudson 

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.

[1] Dep’t of Health and Human Servs. Office of the Inspector Gen., Waivers,  https://oig.hhs.gov/exclusions/waivers.asp (last accessed Jan. 13, 2015).