Questions billers ask › What offenses trigger mandatory exclusion from Medicare and Medicaid?

What offenses trigger mandatory exclusion from Medicare and Medicaid?

Answered from the public Medicare sources on 2026-09-15. The quoted text is the source; the note beneath it is what our AI found. You decide what applies to your claim.

The rule, word for word

“The OIG will exclude any individual or entity that— (a) Has been convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program, including the performance of management or administrative services relating to the delivery of items or services under any such program; (b) Has been convicted, under Federal or State law, of a criminal offense related to the neglect or abuse of a patient, in connection with the delivery of a health care item or service, including any offense that the OIG concludes entailed, or resulted in, neglect or abuse of patients (the delivery of a health care item or service includes the provision of any item or service to an individual to meet his or her physical, mental or emotional needs or well-being, whether or not reimbursed under Medicare, Medicaid or any Federal health care program); (c) Has been convicted, under Federal or State law, of a felony that occurred after August 21, 1996, relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct— (1) In connection with the delivery of a health care item or service, including the performance of management or administrative services relating to the delivery of such items or services, or (2) With respect to any act or omission in a health care program (other than Medicare and a State health care program) [...]”

42 CFR § 1001.101, Subpart B -- Mandatory Exclusions -- § 1001.101 Basis for liability.
Published2026-04-06 Captured2026-04-06
sha256:29bebacb…180e64da · Source

What our AI found in the sources

Mandatory exclusions from federal health care programs under 42 CFR § 1001.101 include: (a) conviction of a criminal offense related to the delivery of an item or service under Medicare or a State health care program; (b) conviction of a criminal offense related to neglect or abuse of a patient in connection with the delivery of a health care item or service; (c) conviction of a felony (after August 21, 1996) relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with delivery of a health care item or service or with respect to any act or omission in a health care program operated or financed by any Federal, State, or local government agency; and (d) conviction of a felony (after August 21, 1996) relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. All mandatory exclusions are for a minimum of 5 years.

Also cited

42 CFR § 1001.102, Subpart B -- Mandatory Exclusions -- § 1001.102 Length of exclusion.
Published2026-04-06 Captured2026-04-06
sha256:29bebacb…180e64da · Source

If this comes up on one of your claims

The quoted paragraph above is what you would put in the appeal or the audit file, with its citation and dates. Verbatim does not tell you how to bill; it shows you the rule as published so the decision is yours and the proof is in writing.

Ask it your own question and get the same thing back: the governing rule, quoted, with a citation that still verifies later.

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