Doctors Banned From Medicare May Get an Easier Shot at a Second Chance

Medicare’s chief watchdog plans to make it easier for doctors who have lost their licenses and gotten new ones to resume billing the program. Under a proposal published on Friday, authorities would have more latitude to reinstate doctors and other professionals banned from Medicare after they’ve been punished by states for misconduct.

The planned change comes even as new Medicare data shows that the federal health program for older Americans pays millions of dollars to doctors whose licenses were revoked but who managed to keep practicing by getting licenses in other states. One doctor convicted of embezzlement in Ohio and barred permanently from practicing medicine there was granted a license in New Mexico, where he collected $660,000 from Medicare in 2012, according to Bloomberg News. A ProPublica report found that doctors banned from state Medicaid programs collected more than $6 million in 2012.

Medicare relies on a loose-knit network of contractors, regulators, and law enforcement agencies to police the $604 billion program. When health-care providers are sanctioned by states, the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services has the power to exclude them from billing Medicare and Medicaid, the state-federal health program for the poor.

But only certain criminal convictions get doctors banned automatically, such as felonies for health-care fraud or patient abuse. The OIG has the discretion to exclude health care providers punished for less serious offenses but isn’t required to do so. The same leeway applies to doctors who have had licenses revoked or suspended “for reasons bearing on professional competence, professional performance, or financial integrity,” according to the OIG’s office.

Under current law, a doctor, nurse, or other licensed health care provider excluded by the OIG for a revoked license would need to recover their original license to get reinstated to Medicare. That applies even to professionals switching professions. Consider a nurse who has lost her license because of a substance-abuse problem and been excluded from Medicare. If, years later, she has reformed and becomes a licensed physical therapist, she will remain ineligible to bill Medicare unless she gets her original nursing license back.

“We regularly are contacted by individuals who have changed professions and never intend to regain their original licenses but for whom the exclusion is a permanent obstacle to practicing a new health-care related profession,” the OIG wrote in its explanation of the rule. The office said it could not comment on pending regulations.

When weighing whether to let banned practitioners back in, the OIG will consider “whether the individual has demonstrated that he or she has satisfactorily resolved any underlying problem that caused or contributed to the basis for the initial licensing action,” among other factors, according to the proposed rule. The agency will also evaluate the risks to patients and to Medicare and Medicaid, as well as any additional sanctions or investigations. Under the rule, the OIG would lean against reinstating people whose exclusions are less than five years old, although exceptions may be made.

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