Hospice OIG Exclusion: The Ban Follows the Work

Hospice OIG exclusion bars a person or company from participating in Medicare, Medicaid and other federal health care programs, cutting off payment for services they provide. The restriction reaches a hospice that bills for an excluded employee’s work. For someone in payroll, billing or management, the question reaches beyond the name on the claim to the person doing the work and the people who kept it going.

An exclusion can also reach the executive directing admissions or the owner arranging referral payments. Civil hospice fraud settlements have combined a company’s agreement to pay with a separate exclusion of the person running it.

What Does Hospice OIG Exclusion Mean for Medicare Payments?

Federal programs cannot pay for an excluded person’s covered work simply because another provider submits the claim. The Department of Health and Human Services Office of Inspector General explains in its 2017 report to Congress that exclusion prevents reimbursement for an individual’s professional services and for services another provider supplies on that individual’s orders or prescriptions. The report also identifies claims for items or services furnished by an excluded person as grounds for civil monetary penalties.

That reaches a familiar hospice arrangement. Medicare pays the hospice a daily rate based on the level of care, as the Centers for Medicare & Medicaid Services explains in Hospice Fast Facts. The provider receives the payment while employees perform the work. Following the work through to the hospice claim therefore means looking beyond who submitted the bill.

Pinnacle Hospice Care illustrates the connection. In July 2016, the Office of Inspector General reached a $50,000 administrative settlement over allegations that the hospice employed an excluded individual who provided items or services to patients that were billed to federal health care programs. The hospice faced the payment consequence for its employee’s work. Billing Medicare for barred services puts the cost on taxpayers.

We trace an excluded employee’s services through the hospice’s Medicare claims with insiders who know the assignments, the payroll and the billing decisions. A staffing record and a claim can describe the same care from opposite ends of the business.

Why Hospice Owners and Managers Matter

Medicare’s hospice enrollment rules reach owners, administrators and medical directors. The enrollment changes effective in January 2024 made hospice administrators and medical directors reportable managing employees.

We compare the disclosed roles with the instructions the staff actually received: who directed admissions, who approved physician arrangements and who decided that billing would continue.

The case against Hospice of the Comforter shows why management belongs in the story. In its November 2013 settlement announcement, the Justice Department said the hospice agreed to pay $3 million over allegations that it billed Medicare for patients who were ineligible. Its former CEO agreed to a three-year voluntary exclusion from federal health care programs. The government alleged that management directed staff to admit all referred patients regardless of eligibility, falsified records and limited physicians’ roles in assessing terminal illness.

A former employee filed the whistleblower case. The complaint described the CEO’s alleged involvement in admitting patients who did not qualify:

The allegation put the executive inside the admission and billing decision. The company separately agreed to enter a corporate integrity agreement requiring procedures and reviews to detect and prevent similar conduct.

What Is the 36 Month Rule for Hospice?

Under the 36-month rule, a covered change in majority ownership within that period after initial enrollment or the most recent majority ownership change does not transfer the hospice’s Medicare provider agreement and billing privileges to the buyer. The buyer must enroll as a new provider and obtain a survey or accreditation.

CMS explained the reason in its enrollment rule: hospices were being sold quickly after enrollment or purchase so the new owner could avoid a survey.

Why Hospice Owners Agree to Exclusion

Mandatory exclusion requires the Office of Inspector General to act. Permissive exclusion gives it a choice, including authority to exclude for false claims and unlawful kickbacks.

The civil hospice cases show how an agreed exclusion can accompany a settlement. Hospice Family Care agreed to a $3,700,000 settlement of false Medicare billing allegations, recorded in the inspector general’s May 2012 enforcement announcement. Its nurse owners agreed to seven-year exclusions from federal healthcare programs. The settlement addressed alleged billing for ineligible patients and levels of care higher than necessary or allowable.

A later resolution reached the former owner of Providence Home Health and Providence Hospice. In December 2020, the Justice Department announced that the former owner agreed to pay $1.05 million and to a five-year exclusion. The allegations included medical-director compensation above fair market value to induce Medicare home-health and hospice referrals. The owner had sold the companies by the time of the announcement.

That case connects payments for hospice referrals with the person who arranged them. Selling the companies did not remove the former owner from that resolution.

What Hospice Screening Records Show

Hospice screening records matter when they connect a person’s identity and status with the work the hospice assigned. Employment and contracting records, management disclosures and the exclusion notice give us different parts of that account. We work with the insider to establish who performed the services, when they performed them and who knew about the exclusion.

Staff files can also reveal how far actual practice has drifted from the organization’s stated controls. In Hospice Deficiencies Pose Risks to Medicare Beneficiaries, its July 2019 evaluation, the Office of Inspector General reviewed selected serious deficiencies and found failures to complete background checks and update employee credentials. The employee file is where a hospice documents who is qualified to provide care:

For someone handling staffing or credentials, that same employee file can connect the person’s exclusion status with the care they actually delivered. We examine it alongside the claims for that work.

The management response matters alongside the screening result. If you know an exclusion was raised internally and the person kept receiving assignments, we want to understand who received that information and what happened to the claims. That is where the staff member’s knowledge can connect an administrative record to a possible whistleblower case.

Hospice LEIE Exclusion and Reinstatement

When an excluded owner or worker returns to a hospice, the question is whether the Office of Inspector General reinstated them. The inspector general’s List of Excluded Individuals/Entities and the person’s status documents matter alongside their actual role.

Reinstatement is not automatic. Medicare Billing Risk Perceptions of Hospitals Operating Under Corporate Integrity Agreements, published in the Journal of Forensic & Investigative Accounting in 2009, describes a separate request to the Office of Inspector General after the exclusion period.

If you have been told an old exclusion has ended, we examine the reinstatement decision and the services the hospice then billed. The Office of Inspector General describes its role as reinstating providers who apply and meet the requirements of their exclusions.

OIG Exclusion and Medicare Enrollment Revocation

Exclusion reaches a person’s or company’s participation in federal healthcare programs. Medicare enrollment revocation removes the provider’s enrollment, as illustrated by the Centers for Medicare & Medicaid Services’ February 2026 enhanced-oversight fact sheet. We connect the agency’s decision to the person or provider it names, then to the work and payments at issue.

When Excluded Work Becomes a Whistleblower Case

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. For hospice insiders with knowledge of the billing, the opportunity lies in explaining how an excluded person’s work continued to generate claims and who made that possible.

When the Work Continued After Exclusion

If you know who kept working, who approved it and how the hospice billed for it, speak with our whistleblower experts about those decisions. We build the case with you and bring in hospice fraud whistleblower lawyers who understand excluded-provider billing and ownership. We stay beside you from the first conversation through the case.