Why Compliance Matters More Than Ever

Every year, the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) investigate thousands of healthcare providers for compliance failures. Many of these cases don’t start with intentional fraud—they start with simple mistakes: an outdated enrollment record, a missed signature, or inconsistent documentation.

But those small issues can snowball into serious sanctions: OIG exclusions, CMS revocations, civil monetary penalties, and even loss of license.

The best way to protect your practice is to prevent problems before they arise.

At National Security Law Firm (NSLF), we’ve seen both sides—our attorneys have worked inside the federal government and now defend healthcare providers nationwide. This gives us unique insight into what triggers investigations, how agencies evaluate compliance, and what you can do to stay off their radar.

Understanding the Risks

The OIG and CMS are both part of the U.S. Department of Health and Human Services (HHS), but they have distinct enforcement roles:

A violation detected by either agency can lead to cascading consequences: a CMS revocation may trigger an OIG exclusion, which can then lead to state Medicaid suspensions and loss of private insurance contracts.

Common Red Flags That Trigger Audits and Sanctions

Avoiding sanctions starts with recognizing what behaviors raise government concern.

Here are the most common OIG and CMS audit triggers we see:

  • Inaccurate or incomplete enrollment information (e.g., outdated addresses, ownership details, or NPIs)

  • Improper billing codes or billing for services not rendered

  • Failure to report adverse actions, such as license suspensions or malpractice settlements

  • Duplicate or excessive claims

  • Billing while excluded (even unknowingly)

  • Untrained or unsupervised staff submitting claims

  • Failure to maintain compliance documentation (policies, audit logs, or training records)

Remember: intent is not required for sanctions. Negligence or oversight alone can justify exclusion or revocation.

Key Steps to Build a Strong Compliance Program

1. Maintain Up-to-Date Enrollment Information

Ensure that all provider and facility details—address, ownership, contact information, NPIs—are current in PECOS and CMS-855 forms. Even small discrepancies can be treated as false statements.

2. Conduct Regular Internal Audits

Quarterly or semiannual audits should verify that billing, coding, and documentation meet CMS standards. Independent reviews by compliance counsel or billing consultants can catch small errors before they escalate.

3. Implement Written Policies and Training

Every employee who touches claims or patient data should complete compliance and HIPAA training annually. Keep signed acknowledgments on file.

4. Monitor the OIG Exclusion List (LEIE)

Screen all employees, contractors, and vendors against the List of Excluded Individuals and Entities (LEIE) at least monthly. Hiring or paying an excluded person can expose your practice to civil penalties.

5. Document Everything

If it isn’t written, it didn’t happen. Maintain:

  • Billing and coding records

  • Training logs

  • Licensure verifications

  • Compliance meeting minutes

  • Corrective action documentation

6. Use Self-Disclosure When Mistakes Happen

If you discover overpayments, false claims, or excluded individuals on staff, voluntary self-disclosure through the OIG Self-Disclosure Protocol can significantly reduce penalties.
CMS has a similar process for overpayment refunds under 42 C.F.R. § 401.305.

7. Designate a Compliance Officer

Even small practices benefit from a point person who oversees training, audits, and investigations. Larger organizations should appoint a dedicated compliance team or retain external counsel for oversight.

What to Do if You Receive a Notice from OIG or CMS

If you receive a revocation, preclusion, or exclusion notice, do not ignore it.
Immediate action is critical to preserve your rights.

  1. Note the deadlines — you generally have 60 days to appeal or request reconsideration.

  2. Stop billing immediately until eligibility is confirmed.

  3. Contact experienced counsel — your initial response often determines whether you can later appeal.

At National Security Law Firm, we can assess your case, file emergency reconsiderations, and work with OIG or CMS to resolve the issue before it escalates into permanent exclusion.

How NSLF Helps Physicians and Practices Stay Compliant

Our firm assists providers at every stage—from prevention to reinstatement. We:

  • Draft and implement written compliance programs

  • Audit internal billing and enrollment records for red flags

  • Review employee rosters against the OIG Exclusion List

  • File self-disclosures or refund reports to mitigate penalties

  • Represent clients in OIG, CMS, and state-level investigations

  • Coordinate reinstatement or appeal when sanctions already exist

Our attorneys’ experience as former federal prosecutors, agency counsel, and military judges gives us unique insight into how compliance decisions are made—and how to resolve them efficiently and professionally.

Led by Duane “Dak” Kees

Led by Duane “Dak” Kees, a former U.S. Attorney with strong relationships throughout the federal government as a result of his service as both a U.S. Attorney and a military judge, our team knows how to work within the system to restore eligibility and rebuild trust with federal healthcare programs.
Learn more about Dak’s background here.

Explore More Resources

If you or someone you know is facing an OIG exclusion or CMS revocation, visit our HHS Exclusion & CMS Revocation Resource Hub for step-by-step guides, timelines, and strategies from our federal healthcare defense team.

At National Security Law Firm, we help physicians, pharmacists, and healthcare providers nationwide navigate reinstatement, appeal, and compliance with precision and integrity.

Why Choose National Security Law Firm

  • Former Federal and Military Lawyers — Our attorneys know how to navigate complex federal compliance systems.

  • Nationwide Representation — We serve clients in every state.

  • 4.9-Star Client Reviews: https://share.google/WxWJ2s8FDsWGZDUeQ

  • Comprehensive Compliance Support — From audits to reinstatement petitions, we cover every phase.

  • Free Consultations — Discuss your situation confidentially before any action is taken.

Protect Your Practice Before Problems Arise

Compliance isn’t just about avoiding penalties—it’s about protecting your license, your livelihood, and your patients’ trust.

At National Security Law Firm, we don’t just fix problems after they happen—we help you prevent them.

Consultations are free, confidential, and pressure-free.


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