Medicaid Exclusion Appeals and
​Reinstatement Applications FAQ

​The New York State Office of the Medicaid Inspector General (OMIG) is very aggressive when it comes to excluding healthcare providers from the Medicaid program.

Fortunately, you have several options to protect your livelihood and career.  You may appeal OMIG’s decision to suspend or exclude you.  You may also apply for reinstatement to the Medicaid program during your period of exclusion.  Either way, you need an exclusion lawyer on your side.  The rules and procedures are complicated, and the deadlines are strictly enforced.

Answers to Frequently Asked Questions (FAQ)

​What are the grounds for exclusion from the Medicaid program?

The New York State Office of the Medicaid Inspector General (OMIG) is authorized to exclude a healthcare provider from the Medicaid program for “unacceptable practices.”  The most common "unacceptable practices" are:

• False claims for services that were never provided
• Overbilling for services that were provided
• Billing for claims that were not medically necessary
• Practicing your profession with a suspended license
• Billing for services provided by an excluded person
• Violations of the anti-kickback statute
• Arrests and criminal charges for certain crimes

​The “unacceptable practice” does not have to involve claims submitted to Medicaid.  For example, a healthcare provider who is arrested for submitting false claims to a private insurance company is usually excluded from Medicaid as soon as OMIG learns of the arrest.

What are the consequences of exclusion from Medicaid?

​If you have been accused of a crime related to the practice of medicine or the provision of healthcare services, OMIG will automatically suspend you from the Medicaid program.  It does not matter that you are innocent until proven guilty.  OMIG will suspend you based on nothing more than an accusation that you did something wrong.

The New York State Department of Health may also withhold payment on pending claims to Medicaid for services already provided, and it may demand repayment of payments it believes you were not entitled to receive.

Who can be excluded from the Medicaid program?

Anyone who provides services to Medicaid recipients can be excluded from the Medicaid program.  In addition, OMIG has the power to exclude companies and individuals who are “affiliates” of a healthcare provider, even if the affiliates are not themselves healthcare providers. 

​Some examples of affiliates who may be excluded from Medicaid are:
• Business partners or persons with an ownership or controlling interest in a provider;
• Employees and managers of the provider;
• Subcontractors who earned more than $25,000 a year from dealing with the provider.

​​How much time do I have to appeal my exclusion from Medicaid?

After learning of an unacceptable practice, OMIG will send you a Notice of Proposed Action.  The notice will state that OMIG intends to exclude you from the Medicaid program or impose another sanctions, such as a censure.  You have only 30 days from a Notice of Proposed Action to challenge the exclusion.  In that short time period, you must pull together all of your factual and legal arguments against exclusion, and you must support your arguments with evidence.

In some circumstances, OMIG will issue a Notice of Immediate Sanction.  A Notice of Immediate Sanction may be issued when the provider has been convicted of a crime related to Medicaid fraud, has been charged with a healthcare crime that is a felony, has been found guilty of professional misconduct related to an unacceptable practice, or has engaged in other conduct that suggests the provider is a danger to the public.  You have only five days to respond to a Notice of Immediate Sanction.

The deadlines to challenge a Medicaid exclusion are strictly enforced.  It is critical that you get an experienced Medicaid exclusion appeals lawyer on your side immediately.  Your appeal will be dismissed without review if you miss the filing deadline.  You also need to act right away because your lawyer will need time to develop your arguments and evidence for a successful appeal.

How do I appeal my exclusion from Medicaid?

In order to win your exclusion appeal, you must convince ​OMIG that they made a mistake of fact or that excluding you from the Medicaid program was unreasonable.  This requires pulling together all the evidence and legal arguments in your favor in a very short period of time.

You need an experienced Medicaid exclusion appeals attorney who knows the types of evidence and legal arguments that convince OMIG to reconsider its decision to exclude you.  You also need a lawyer who can help you stroke the right balance between accepting responsibility for your conduct and arguing that it doesn't justify your exclusion from the Medicaid program.

​How do I apply for reinstatement to Medicaid?

Reinstatement to the Medicaid program is not automatic once your period of exclusion ends.  You must apply for reinstatement.  You may also apply for reinstatement during your period of exclusion.  In essence, you may ask OMIG to shorten your period of exclusion by applying for reinstatement before it ends.

You may only apply for reinstatement once every 12 months.  If your application for reinstatement is denied, then you must wait another year before applying again.

Applying for reinstatement requires careful thought and strategy.  While the process for reinstatement is essentially the same as the original enrollment process, the substance of your application may be different.  You need to provide evidence that you have complied with all requirements of any criminal sentence such as court-ordered restitution and probation.  You need to provide evidence that you have complied with any professional disciplinary sanctions.  Most importantly, you need to convince OMIG that, whatever caused you to be on the exclusion list in the first place, you will not end up on the exclusion list ever again.

What are the criteria for reinstatement to Medicaid after a period of exclusion?

OMIG does not provide a list of criteria for reinstatement after a period of exclusion, and there are no publicly-available decisions to serve as precedents.

The best way to increase your chances of a successful reinstatement application is to consult with an attorney who has handled a large number of reinstatement applications.  Given the importance of your reinstatement application, it makes sense to retain a lawyer who specializes in OMIG exclusion appeals and reinstatement applications.

Why should I choose The Howley Law Firm for my Medicaid exclusion appeal and reinstatement application?

​Our lawyers have more than 30 years of experience representing healthcare companies and medical professionals.  Our practice is focused on Medicare and Medicaid fraud, and we are recognized experts in this complex area of law.  In fact, we train other lawyers with our Continuing Legal Education (CLE) courses on the False Claims Act and Advanced Topics in Medicare and Medicaid Fraud.

Our experience includes working as registered lobbyists in Albany and Washington, D.C., negotiating with prosecutors, investigators and auditors, trying cases before judges and juries throughout the United States, and arguing appeals in state and federal courts including in the U.S. Supreme Court.

Consult with an Exclusion Appeals and Reinstatement Lawyer Today

Call (212) 601-2728