A Medical Justice member recently asked a simple question with a complicated answer: “If CMS pulls my billing, am I ‘excluded’? And is that the same as the Medicare preclusion list?” Close cousins, not identical twins. Here’s the field guide I wish more practices kept on the bulletin board.
Quick Definitions in Plain English
OIG Exclusion (List of Excluded Individuals and Entities – LEIE). A federal disability. If the HHS Office of Inspector General excludes you, you cannot participate in ANY federal health care program—Medicare, Medicaid, TRICARE, VA—directly or indirectly. No billing under your name, no billing through a group, no ordering or prescribing paid by a federal program. Period. The legal hook lives in 42 U.S.C. §1320a-7. Office of Inspector General+1
CMS Revocation. A Medicare enrollment action. CMS can revoke your Medicare billing privileges under 42 C.F.R. §424.535 for a laundry list of reasons—felony convictions, on-site findings that you’re “not operational,” abuse of billing numbers, and more. Revocation carries a re-enrollment bar (often years). You might still hold a state license and even practice privately; you just can’t bill Medicare during the bar. Legal Information Institute+1
Medicare Preclusion List. A CMS list used by Medicare Advantage (Part C) and Part D. If you’re precluded, MA plans cannot pay you for services and Part D plans cannot pay for your prescriptions. You land here when you’re revoked with a bar and CMS thinks the conduct is “detrimental,” when CMS concludes it could have revoked you even if you weren’t enrolled, or when you’re OIG-excluded. Appeals run under Part 498. Legal Information Institute+2e-CFR+2
Who Swings the Hammer—And Where the Blow Lands
- OIG exclusion is imposed by the Inspector General and applies across all federal programs. Think of it as a system-wide red card. Office of Inspector General+1
- Revocation is imposed by CMS and affects traditional Medicare billing privileges. It can be the spark that lights the preclusion fire. Legal Information Institute
- Preclusion is curated by CMS and enforced by Medicare Advantage and Part D plans at the claims level. Once you’re on it, MA and Part D plans must deny payment. Legal Information Institute
Triggers: How People End Up on Each List
OIG mandatory exclusions include program-related crimes, patient abuse or neglect, and certain felony health-care fraud or drug offenses. Permissive exclusions cover a wider set of conduct. Legal Information Institute You’ll have more luck with fighting a permissive exclusion than a mandatory exclusion.
Example of mandatory exclusion: felony conviction related to healthcare fraud. Example of permissive exclusion: misdemeanor relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct—in connection with the delivery of a health care item or service. The length of time one is excluded is based on this chart. Office of Inspector General
Revocation grounds include being “not operational,” failing to meet enrollment standards, certain adverse actions, abusive billing patterns, and specific felonies. A re-enrollment bar ranges from 1–10 years and lately CMS has not been shy about the upper end. Legal Information Institute Centers for Medicare & Medicaid Services+2
Preclusion usually rides on a revocation with a bar where CMS deems the underlying conduct detrimental. CMS may also preclude someone not presently enrolled if the facts would have justified revocation. So, you can be non-participating and still end up on the preclusion list. Anyone excluded by the OIG is placed on the preclusion list as of the exclusion date. e-CFR+1
Payment Consequences at the Claim Level
Excluded = no payment by any federal program for items or services you furnish, order, or prescribe—directly or indirectly. Even a group’s claim can be tainted if an excluded individual touched the service. Office of Inspector General+1
Revoked = traditional Medicare won’t pay your claims; you cannot use another TIN or reassignment as a workaround during the bar. MA and Part D may still pay unless you are also precluded. Legal Information Institute
Precluded = Medicare Advantage plans deny payment for services you furnish; Part D plans deny payment for your prescriptions. Beneficiaries can’t appeal a payment denial based solely on your preclusion status. Legal Information Institute+1
How Long You’re Benched
OIG exclusion periods: five years minimum for mandatory categories; permissive periods vary. Reinstatement is not automatic.
Revocation bars: CMS sets a re-enrollment bar between 1 and 10 years, tied to the seriousness of the conduct. Legal Information Institute
Preclusion duration: generally matches the revocation bar; felony-based preclusions can run 10 years from conviction unless CMS shortens it. e-CFR
Where the Lists Live—And Who Must Check Them
OIG Exclusion. LEIE (List of Excluded Individuals/Entities) is PUBLIC, updated monthly. Every compliance program should be checking employees, contractors, and referring sources against it. State Medicaid agencies often maintain their own exclusion rosters too.
Preclusion list is distributed to MA and Part D plans, not broadly posted for the public. Plans must screen against it and deny payment. Many providers first “learn” of preclusion when a plan stops paying.
Revocation status resides in PECOS/Medicare enrollment files and arrives via direct CMS notice. Your billing vendor won’t catch this for you.
Practical Flowchart (No Whiteboard Required)
- If you’re OIG-excluded: you are automatically precluded for MA/Part D. All federal program claims are radioactive. Stop federal program work, seek counsel, and evaluate grounds for early reinstatement only after the exclusion period ends.
- If you’re CMS-revoked (not excluded): traditional Medicare is off the table; MA/Part D may still pay unless CMS places you on the preclusion list. Watch for preclusion letters and appeal deadlines; consider corrective action plans where available.
- If you’re CMS-precluded (with or without revocation): MA services and Part D prescriptions won’t be paid. Traditional Medicare payment depends on whether there’s also a revocation.
Compliance Moves That Actually Help
Tight enrollment hygiene. Keep addresses, practice locations, ownership, and adverse actions current in PECOS. Many revocations start with “not operational” findings or stale disclosures.
Watch your mail. Revocation and preclusion rights die fast if letters sit unopened. A surprising number of appeals are lost to silence.
If trouble looms, build the record early. Part 498 appeals are evidence-driven. Fix what you can fix, show remediation, and anchor arguments in the regulation that actually applies.
The Take-Home
Exclusion, revocation, and preclusion often travel together, yet they spring from different statutes, target different payment lanes, and offer different appeal paths. Treat exclusion as a federal program death sentence until lifted. Treat revocation as loss of traditional Medicare billing with a bar you must outlast or overturn. Treat preclusion as the MA/Part D gatekeeper that can block payment even if you never enrolled in Medicare.
If you want a slogan for the break room: open your mail and respond quickly. And get a lawyer. I’ll say, it beats learning you’re on a list only when the claims stop clearing.
What do you think?
