| (a) The OIG may exclude from participation in Titles
V, XVIII, XIX, XX, or CHIP programs any person if it determines that
the person:
(1) commits a program violation;
(2) is affiliated with a person who commits a program
violation;
(3) commits an act for which damages, penalties, or
liability could be or are assessed by the OIG;
(4) is a person not enrolled as a provider whose health
care license, certification, or other qualifying requirement to perform
certain types of service is revoked, suspended, voluntarily surrendered,
or otherwise terminated such that the provider is unable to legally
perform their profession due to loss of their license, certification,
or other qualifying requirement;
(5) could be excluded for any reason for which the
Secretary of the United States Department of Health and Human Services,
its Office of Inspector General, or its agents could exclude such
person under 42 U.S.C. §1320a-7(b) or 42 C.F.R. Part 1001 or
1003;
(6) is found liable for any violation under subsection
(c) of Texas Human Resources Code §32.039 that resulted in injury
to a person who is 65 years of age or older, a person with a disability,
or a person younger than 18 years of age;
(7) is found liable for any violation under subsection
(c) of Texas Human Resources Code §32.039 that did not result
in injury to a person 65 years of age or older, a person with a disability,
or a person younger than 18 years of age; or
(8) has been excluded from participation in Medicare
or any other federal health care programs.
(b) The OIG may exclude a person without sending prior
notice of intent to exclude in the following circumstances:
(1) The OIG determines that the person is or may be
placing the health and/or safety of persons receiving services under
an HHS program at risk;
(2) a person fails:
(A) to grant immediate access to the OIG or to a requesting
agency upon reasonable request;
(B) to allow the OIG or a requesting agency to conduct
any duties that are necessary to the performance of their official
functions; or
(C) to provide to the OIG or a requesting agency as
requested copies or originals of any records, documents, or other
items, as determined necessary by the OIG or the requesting agency;
(3) the person engages in acts that violate 42 C.F.R. §1001.1401
(hospital's failure to comply with corrective action plan required
by the Centers for Medicare and Medicaid Services);
(4) the person engages in acts that violate 42 C.F.R. §1001.1501
(default on health education loan or scholarship obligations);
(5) the person engages in acts that violate 42 C.F.R. §1001.901
(false or improper claims);
(6) the person engages in acts that violate 42 C.F.R. §1001.951
(fraud and kickbacks and other prohibited activities);
(7) the person engages in acts that violate 42 C.F.R. §1001.1601
(violations of the limitations on physician charges);
(8) the person engages in acts that violate 42 C.F.R. §1001.1701
(billing for services of assistant at surgery during cataract operations);
or
(9) the person has been excluded from the Medicaid
program and obtains a new provider number without completing the reinstatement
and re-enrollment process as required by §371.1719 of this division
(relating to Recoupment of Overpayments Identified by Audit).
(c) When the OIG issues a final notice of exclusion,
the final notice states:
(1) the requirements and procedures for reinstatement;
(2) whether the OIG will also cancel any agreement
held by the person to be excluded; and
(3) a statement of the person's right to request a
formal administrative appeal hearing regarding the exclusion.
(d) Scope and effect of exclusion.
(1) An exclusion becomes effective on the following:
(A) the date of the final notice of exclusion, if the
exclusion is based on a health or safety risk as described in subsection
(b)(1) of this section;
(B) the date of the original request for records, if
the exclusion is based on failure to provide access as described in
subsection (b)(2) of this section;
(C) if the exclusion is upheld at an administrative
hearing based upon subsection (b)(1) of this section, the effective
date is made retroactive to the date of the final notice; and
(D) if the exclusion is upheld at an administrative
hearing based upon subsection (b)(2) of this section, the effective
date is made retroactive to the date of the original request for records.
(2) An exclusion remains in effect for the period indicated
in the final notice of exclusion. The person is not eligible to apply
for reinstatement or re-enrollment as a provider until the exclusion
period has elapsed.
(3) Unless a person is reinstated and re-enrolled as
a provider in the Texas Medicaid program, no payment is made by the
Medicaid program for any item or service furnished or requested by
an excluded person on or after the effective date of exclusion.
(4) An excluded person is prohibited from:
(A) personally or through a clinic, group, corporation,
or other association or entity, billing or otherwise requesting or
receiving payment from any Title V, XVIII, XIX, XX, or CHIP programs
for items or services provided on or after the effective date of the
exclusion;
(B) providing any service pursuant to the Medicaid
program, whether or not the excluded person directly requests Medicaid
program payment for such services;
(C) assessing care or ordering or prescribing services,
directly or indirectly, to Title V, XVIII, XIX, XX, or CHIP recipients
after the effective date of the person's exclusion; and
(D) accepting employment by any person whose revenue
stream includes funds from a Title V, XVIII, XIX, XX, or CHIP program.
(5) If, after the effective date of an exclusion, an
excluded person submits or causes to be submitted claims for services
or items furnished within the period of exclusion, the person may
be subject to civil monetary penalty liability under §1128A(a)(1)(D)
and criminal liability under §1128B(a)(3) of the Social Security
Act in addition to sanctions or penalties by the OIG.
(6) In accordance with federal and state requirements,
when the OIG excludes a person, the OIG may notify each state agency
administering or supervising the applicable state health care program,
as well as the appropriate state or local authority or agency responsible
for licensing or certifying the person excluded. If issued, notification
includes:
(A) the facts, circumstances, and period of exclusion;
(B) a request that appropriate investigations be made
and any necessary sanctions or disciplinary actions be imposed in
accordance with applicable law and policy; and
(C) a request that the state or local authority or
agency fully and timely inform the OIG with respect to any actions
taken in response to the OIG's request.
(7) The OIG notifies the public of all persons excluded.
(8) A person who has been excluded from the Texas Medicaid
or CHIP program is excluded from the Texas Medicaid and/or CHIP program
in every other state and from the Medicare program pursuant to each
program's applicable state or federal authority. When exclusion from
the Texas Medicaid and/or CHIP program is based on the person's exclusion
from Medicare, or from another state's Medicaid or CHIP program, the
prohibitions enumerated in paragraph (4) of this subsection may apply.
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