Kingsfield · Research · Healthcare & Life Sciences

Must the government exclude a provider from Medicare after a conviction related to delivery of a health care item or service?

Published 2026-06-23 · U.S. federal law

The Secretary must exclude from participation in all Federal health care programs any individual or entity convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program.

The answer

The mandatory exclusion

42 U.S.C. § 1320a-7(a) directs the Secretary to exclude from participation in any Federal health care program any individual or entity convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program, including convictions for patient abuse, felony health care fraud, and felony controlled-substance offenses.

Effect of exclusion

An excluded provider may not bill, and Federal health care programs may not pay, for items or services the provider furnishes during the exclusion period. The exclusion is mandatory once a qualifying conviction is established.

The judged input

What the AI drafted

Submitted to the judge

This is an excerpt from a draft Medicare enrollment compliance memo — the kind of work product a lawyer generates with a legal-AI drafting tool, then has to stand behind. Kingsfield does not write it; it rules on the citations the model put in it. This draft cites two authorities; one of them is wrong.

AI draft excerpt — Medicare enrollment compliance memo

The Company has acquired a physician practice in which one principal was recently convicted of felony health care fraud. Under 42 U.S.C. § 1320a-7(a), the Secretary must exclude from participation in Federal health care programs any individual convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program. We advise that the convicted principal cannot remain in any role that would cause the practice to bill Medicare for his services. The exclusion authority for this conviction arises under 42 U.S.C. § 1320a-7b.

The judge ruled on every citation as the draft used it — it accepted 42 U.S.C. § 1320a-7(a) and rejected 42 U.S.C. § 1320a-7b. Here is why.

The verdict

How Kingsfield ruled

Ruled 2026-06-23

Each citation in the draft above was submitted to the Kingsfield judge and ruled against the primary-law corpus — Accept, Reject, or Inconclusive, per citation. These are live verdicts, not editorial. Each card shows the claim the draft made and the verbatim authority the verdict was rendered against.

Accept42 U.S.C. § 1320a-7(a)

The draft claimed: The Secretary shall exclude from participation in any Federal health care program any individual or entity convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program.

“§ 1320a The Secretary shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title ):”

Cite found; proposition supported by the cited text.

Reject42 U.S.C. § 1320a-7b

The draft claimed: Section 1320a-7b is the provision that requires the Secretary to exclude from Federal health care programs an individual convicted of an offense related to delivery of a health care item or service.

Cite found, but the cited text does not support the claim. 42 U.S.C. 1320a-7b sets out criminal penalties for health care program fraud and the Anti-Kickback Statute; the mandatory administrative exclusion following a qualifying conviction is imposed by 42 U.S.C. 1320a-7(a). Regenerate with the correct authority.

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This page is legal information, not legal advice, and does not create an attorney-client relationship. The draft shown is an illustration of a typical AI answer; verdicts reflect the cited authority in the Kingsfield corpus as of the ruling date shown above.