Houston Medicare Exclusion Attorneys

Facing OIG Exclusion, Appealing One, or Seeking Reinstatement? We Defend Healthcare Providers Nationwide

UPDATE – July 21, 2026: The Department of Health and Human Services (HHS) granted the Centers for Medicare and Medicaid Services (CMS) the authority to exclude providers from federal healthcare programs. Until now, only the HHS Office of Inspector General (OIG) could impose an exclusion. Now, two agencies hold that power.

Medicare exclusion does more than end your Medicare billing. Once your name goes on the federal exclusion list, no federal healthcare program can pay for any item or service you order, prescribe, or provide. State Medicaid programs, hospitals, and private payers usually follow.

Most providers still have room to change the outcome. If you received a Notice of Intent to Exclude, you have a limited window to respond before exclusion takes effect. If you are already excluded, you can challenge the decision or apply for reinstatement once your exclusion period ends. Our Houston healthcare attorneys handle all three, for providers in Texas and across the country.

Call (713) 783-3110 or contact us online to speak with an attorney about your exclusion matter.

On This Page

• What Is Medicare Exclusion?
• What Changed in 2026: CMS Can Now Exclude You
• Mandatory and Permissive Exclusions
• How Long Does a Medicare Exclusion Last?
• The Consequences of Exclusion
• Received a Notice of Intent to Exclude?
• Appealing a Medicare Exclusion
• Medicare Reinstatement
• Employers: Screen for Excluded Practitioners
• Why Hendershot Cowart P.C.?
• Common Questions About Medicare Exclusion

What Is Medicare Exclusion?

Exclusion is the federal government's authority to bar an individual or an entity from participating in Medicare, Medicaid, TRICARE, VA programs, and every other federally funded healthcare program. It comes from a section of the Social Security Act that providers and compliance teams often call the exclusion statute.

An exclusion is not limited to the program where the conduct occurred. If you are excluded because of a Medicaid billing issue in one state, you are out of Medicare, Medicaid, and every other federal healthcare program in every state.

What Changed in 2026: CMS Can Now Exclude You

In the past, exclusion authority belonged to the Office of Inspector General alone. On July 21, 2026, HHS expanded that exclusion authority to CMS. Federal officials described the change as a “force multiplier,” and CMS has said it will use the power judiciously.

What this means for you: the agency that already controls your Medicare enrollment and can revoke your billing privileges can now also exclude you outright.

That matters because CMS reaches providers differently than the OIG does. CMS interacts with your enrollment file, your revalidations, and your claims data constantly. OIG exclusions have historically followed convictions, license actions, and fraud investigations. A CMS-initiated exclusion could begin with something as routine as an enrollment discrepancy or a revocation that escalates.

This means that Medicare audits and investigations now carry a second layer of risk. If you are dealing with a revocation, a deactivation, or a CMS enrollment action right now, treat it as a potential exclusion matter.

Mandatory and Permissive Exclusions

Federal law divides exclusions into two categories. Which one applies to you determines how much room you have to negotiate.

Mandatory Exclusions

The government has no discretion here. Exclusion is required if you are convicted of:

• Medicare or Medicaid fraud
• Patient abuse or neglect
• Felony convictions for other health care-related fraud, theft, or other financial misconduct
• Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances

If a mandatory exclusion is imposed at the minimum period, the length cannot be appealed. Your arguments are limited to whether the conviction legally qualifies as a basis for exclusion at all.

Permissive Exclusions

Here the government has discretion, which means there is something to argue about. Grounds include (but not limited to):

• Misdemeanor convictions related to healthcare fraud other than Medicare or a state health program
• Fraud in a program (other than a healthcare program) funded by any federal, state or local government agency
• Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
• Suspension, revocation, or surrender of a license to provide healthcare for reasons bearing on professional competence, professional performance, or financial integrity
• Billing substantially more than usual charges or furnishing services substantially in excess of patient needs or below professionally recognized standards
• Submission of false or fraudulent claims to a federal healthcare program
• Engaging in unlawful kickback arrangements
• Defaulting on health education loan or scholarship obligations
• Controlling a sanctioned entity as an owner, officer, or managing employee

Because these are discretionary, mitigating evidence, corrective action, and a documented compliance response can affect whether an exclusion is imposed and how long it runs.

How Long Does a Medicare Exclusion Last?

Aggravating factors extend these periods. Mitigating factors can shorten them, but only when the exclusion period already exceeds the five-year minimum. 

The Consequences of Exclusion

The payment prohibition is broader than most providers expect. No federal healthcare program will pay for:

• Any item or service you furnish, on or after your exclusion date
• Any item or service furnished on your order or prescription, if the person providing it knew or should have known you were excluded
• Your services when billed through a group practice, a hospital, or a managed care entity
• Administrative and management services, including work that is not separately billable
• Services you provide after switching roles or employers within a healthcare organization

Beyond federal healthcare programs, exclusion may also trigger:

• Termination from Texas Medicaid and other state Medicaid programs
• Loss of hospital privileges
• Removal from commercial insurance panels
• A licensing board investigation
• Debarment from federal contracts (meaning you cannot bid on or receive federal contracts, grants, or subcontracts)

The Penalties for Billing During Exclusion

Excluded providers should not submit any claims to federal healthcare programs during their exclusion period. Doing so creates civil and criminal liability, and will be considered against them in any future reinstatement application.

The penalties reach your employer, too. An entity that employs or contracts with someone it knew or should have known was excluded is also subject to civil monetary penalties. "Should have known" is a low bar: deliberate ignorance or reckless disregard is enough, and the government does not have to prove intent to defraud.

Received a Notice of Intent to Exclude?

For most permissive and some mandatory exclusions, OIG will send a written Notice of Intent to Exclude (NOI) detailing the case against you and the proposed penalty. An NOI does not mean you are excluded. It does mean that the OIG is considering the action and is giving you a chance to present your side of the case.

Here is how the process works:

1. You have 30 days to submit a written response. That response can address whether exclusion is warranted and/or contest the length of the proposed exclusion. You can present evidence, character references, or proof of corrected behavior to support your case.
2. In permissive exclusion cases, you can also request oral argument before an OIG official prior to any decision. Requesting it does not prevent you from submitting a written response as well.
3. The government will consider what you submit. These notices exist precisely because the decision has not been made.

Thirty days sounds like more time than it is. Building a persuasive response usually means gathering billing records, license history, compliance documentation, and often an independent audit. Providers who wait two weeks to call an attorney lose half the window.

What Triggers an NOI?

• Most permissive exclusions: Because permissive exclusions are discretionary, the OIG almost always issues an NOI to weigh mitigating or aggravating circumstances before deciding.
• Mandatory exclusions exceeding five years: By law, mandatory exclusions carry a strict five-year minimum. If the OIG wants to impose a longer penalty, they must issue an NOI detailing the proposed extension.
• When it's skipped: If the OIG pursues a standard, baseline five-year mandatory exclusion, they can skip the NOI completely and issue an immediate Notice of Exclusion.

If your matter has not reached the notice stage but you are dealing with an OIG subpoena, a Civil Investigative Demand, a False Claims Act inquiry, a UPIC audit, a RAC audit, an insurance SIU audit, or a managed care investigation, exclusion may already be on the table. 

Appealing a Medicare Exclusion

If a Notice of Exclusion is issued, the exclusion takes effect 20 days after the date of the notice. Your appeal rights run on a separate clock.

You have 60 days from receipt of the notice to request a hearing before an Administrative Law Judge (ALJ). That deadline is strictly enforced.

What an Administrative Law Judge Can Decide

The hearing is limited to two questions:

• Does a legal basis for the exclusion exist?
• Is the length of the exclusion unreasonable?

The second question disappears when the government imposes a mandatory exclusion at the minimum period.

What an Administrative Law Judge Cannot Decide

If your exclusion is based on a criminal conviction, a civil judgment, or another prior adjudication, you cannot relitigate the underlying facts. No collateral attack on the conviction is permitted, on substantive or procedural grounds. Neither is an argument based on your professional record, your community standing, or the hardship exclusion will cause your patients.

This narrowing is why appeals are won on legal framing rather than on sympathy. The productive questions are whether the conviction actually fits the exclusion category the government invoked, whether the aggravating factors it cited are supported, and whether the period it chose is defensible.

After the Administrative Law Judge

An adverse decision can be appealed to the HHS Departmental Appeals Board. After a final Board decision, judicial review is available in federal district court. Federal courts review whether the agency's decision is supported by substantial evidence. They do not reweigh evidence or revisit the underlying conviction.

Medicare Reinstatement

Reinstatement is never automatic. You must actively request and submit a reinstatement application to the OIG. Until the government grants reinstatement in writing, you remain excluded, and billing in the interim carries civil and criminal liabilities as described above.

How the Process Works

• Timing. You may submit a written reinstatement request beginning 90 days before your exclusion period expires. 
• Documentation. The government will require you to submit specified information and authorization to obtain records from private insurers, peer review bodies, probation officers, professional associates, and investigative agencies. Refusing authorization or failing to provide required information keeps the exclusion in place.
• Processing. Plan for 90 to 120 days for the government to review and rule on a reinstatement application. The exact timeframe depends on the complexity of your case, the agency's current caseload, and how quickly you respond to requests for information.
• Removal from the LEIE. If your application is approved, expect to be formally removed from the List of Excluded Individuals/Entities (LEIE) within roughly 30 days.
• Denial. If reinstatement is denied, you have 30 days to submit additional material. Once the denial is final, you cannot reapply for at least one year, and the denial is not subject to further administrative or judicial review.

The OIG will authorize reinstatement only if it determines that these conditions are met:

1. The period of exclusion has expired
2. There are reasonable assurances that the types of actions that formed the basis for the original exclusion have not recurred and will not happen again
3. There is no additional basis to continue the exclusion
4. If your exclusion was based on a license action, your license must be restored first

Reinstatement Applications Are Won During the Exclusion Period 

Do not wait until 90 days before your exclusion period expires to demonstrate that you no longer pose a threat to program integrity or patients. OIG wants proof that the conduct that led to your exclusion has stopped and will stay stopped. 

Payment of all fines, overpayments, and debts owed to federal, state, or local governments related to Medicare, Medicaid, or other federal health care programs is required. Billing while under an exclusion will damage your reinstatement application. Participating in a compliance program, cooperating with oversight authorities, and evidence of professional rehabilitation will strengthen your application. 

Our team of regulatory compliance attorneys can help you start building that record of compliance and rehabilitation now.

Employers: Screen for Excluded Practitioners

The federal government maintains a public database of excluded individuals and entities, updated regularly as exclusions and reinstatements are processed. Texas maintains its own exclusion list for the state Medicaid program. A provider can appear on one and not the other.

If you are hiring, screening is not optional. Healthcare entities are expected to screen employees, contractors, and vendors at hire and monthly after that. Employing an excluded person, even unknowingly, exposes your organization to per-item penalties.

Why Hendershot Cowart P.C.?

Since 1987 – nearly 40 years – Hendershot Cowart P.C. has represented healthcare providers and healthcare entities before state regulators and federal agencies. Since 2021 alone, our attorneys have defended more than 100 state and federal healthcare investigations and protected the licenses of dozens of medical professionals.

Talk to us if you:

• Are under investigation or facing an enforcement action that could lead to exclusion
• Received a Notice of Intent to Exclude or a Notice of Exclusion
• Are appealing an exclusion decision or a CMS revocation
• Want to seek reinstatement after your exclusion period ends

What you file first shapes everything that follows.

Call (713) 783-3110 or contact us online to schedule a case review. We represent providers in Houston, throughout Texas, and nationwide.

Common Questions About Medicare Exclusion

Medicare exclusion matters are time-sensitive. Call (713) 783-3110 or contact us online to speak with a Medicare exclusion lawyer in Houston.