• Proposed "Substantially In Excess" Regulations Withdrawn
  • July 9, 2007
  • Law Firm: Baker & Hostetler LLP - Houston Office
  • On June 18, 2007, the Office of Inspector General (“OIG”) withdrew proposed regulations intended to provide guidance on the OIG's exclusion authority under section 1128(b)(6)(A) of the Act. Section 1128(b)(6)(A) grants the OIG authority to exclude any individual or entity from participation in any federal health care program if the Secretary determines that the individual or entity submitted bills or requests for payment under Medicare or Medicaid “substantially in excess of such individual or entity's usual charges.” The proposed regulations defined the term “substantially in excess” to mean those charges that are more than 120 percent of an individual or entity's usual charges or costs. After reviewing the over 300 timely comments that were received, the OIG determined to withdraw the proposed regulation because (1) it concluded that it did not have sufficient information to establish a single, fixed numerical benchmark for “substantially in excess” which could be applied equitably across health care sectors, and (2) it had concerns that the final rule might have the unintended effect of increasing health care costs across the industry. Accordingly, the OIG will continue to evaluate billing patterns of individuals and entities on a case-by-case basis to assess whether Medicare or Medicaid are charged substantially more than other payors. The full text of the withdrawal can be viewed by going to: http://www.oig.hhs.gov/authorities/docs/FR Notice Withdrawal of Substantially in Excess Rule.pdf.