Ineligible Organizations

Lakeland Care shall exclude organizations from participation in the provider network if any of the following categories are met (references to the Act in this section refer to the Social Security Act).

Entities which could be excluded under section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has a direct or indirect ownership or control interest of 5% or more in the entity, or a person with beneficial ownership or control interest of 5% or more in the entity has:

  • Been convicted of any of the following crimes:
    • Program related crimes, i.e., any criminal offense related to the delivery of an item or a service under Medicare or Medicaid. (See Section 1128(a) (1) of the Act);
    • Patient abuse, i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (See Section 1128 (a) (2) of the Act;
    • Fraud, i.e., a State or Federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by Federal, State or local government. (See Section1128 (b)(1) of the Act);
    • Obstruction of an investigation, i.e., conviction under State or Federal law of interference or obstruction of any investigation into any criminal offense described directly above (See Section 1128 (b) (2) of the Act;
    • Offenses relating to controlled substance, i.e., conviction of a State or Federal crime relating to the manufacturing, distribution, prescription or dispensing of a controlled substance. (See Section 1128 (b) (3) of the Act;
  • Been excluded from participation in Medicare or a State Health Program. A State Health Care Program means a Medicaid program or any State program receiving funds under title V or title XX of the Act. (See Section 1128(b)(8)(iii) of the Act.)
  • Been assessed a Civil Monetary Penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 11238A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (See Section 1128(b)(8)(B)(ii) of the Act.)