Exclusion Compliance

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Understanding OIG Exclusions

OIG Exclusions Screening Process

What is OIG Exclusion Screening?

Exclusion screening is the process of verifying that an employee or potential is not classified as an excluded individual who is prohibited from participation in any Federal health care program.

How does an employer find out if an individual or entity is excluded?

The OIG does not issue individual warnings or notifications regarding excluded individuals. Employers are required to search the Federal exclusions database and SAM.gov , as well as each individual state’s Medicaid Exclusion Database, to verify each one of their employees. Various states require additional searches as well.

How is an exclusion screening search performed?

The employer inputs the employee’s (or potential hire’s) name, date of birth into the database. The database returns a list of potential matches, including individuals with similar names. The employer must then independently verify whether or not the employee in question is, indeed, the same person as the excluded individual. Employers are also required to check all versions of each employee’s name, including maiden names, combined names (ie. Smith-Jones; Smith; and Jones), and name diminutives (ie. Robert/Bob).

Is the OIG Exclusions list the only database that must be searched?
No, there are also other federal exclusions lists and state level databases that must be accessed for an exclusions search. Examples are:

● The General Services Administration (GSA) Systems for Awards Management (SAM)
● Office of Foreign Assets and Control (OFAC)
● Drug Enforcement Agency (DEA) Excluded Parties List
● State Medicaid Exclusion Lists

Are employers really required to search each and every state’s data files?

Yes. Although the OIG does maintain its own database of excluded individuals, individual states may exclude individuals for reasons other than the ones cited by Federal law, without immediately reporting to the OIG or to other states. The only way for employers to ensure compliance with the mandated requirement is to conduct a nationwide search each and every month.

How often should employers and healthcare providers perform exclusion screening?

All employees must be verified against all exclusion databases, each and every month.

Is there any easier way to perform exclusion screening?

Exclusion screening software, designed specifically for this purpose, can lighten the load of exclusion screening considerably.  The best software packages make exclusion screening virtually effortless.

Employing an Excluded Individual

Consequences to Employing an Excluded Individual

What are the ramifications of keeping an excluded individual on staff?

By law, companies or facilities that participate in government health care programs may not employ an excluded individual. Fines for violation typically range between $30,000 and $300,000.

Can an OIG fine be reversed if the employer was unaware of the excluded status of an excluded employee?

No. Ignorance of the employee’s status is not an acceptable excuse. Employers are required to screen every employee, across every Federal and State database, every month, including all variations of the employee’s name, such as maiden names and name diminutives.

Can an employer bill for services performed by the excluded individual?

Employers will not receive reimbursement from Federal health care programs (including Medicare, Medicaid, TRICARE, and the Veterans Health Administration) for any treatment or service performed by the excluded individual, nor for any treatment or medication prescribed by the excluded individual.

Can an employer be sued for mistakenly firing an employee thought to be an excluded individual?
Yes, an employer may be sued. Identical names commonly appear during the exclusions search screening process. It is the responsibility of an employer however to further verify that an employee or potential hire is in fact, excluded.
What are some of the ways to further verify if an individual is the same person appearing on the OIG Exclusions list?
The OIG Online Searchable Database will ask for the first and last name of the individual. Searchers can further establish the individual’s identity by matching the individual’s:

● Date of birth
● Address
● Social Security Number

Exclusions FAQS

Quick OIG Exclusion Basics

Which government agency handles OIG Exclusions?
The Office of Inspector General (OIG) handles OIG Exclusions. It is a part of the U.S. Department of Health and Human Services (HHS). The HHS-OIG is responsible for combating federal healthcare fraud, waste and abuse through OIG Exclusions.
What is an OIG Exclusion?

Exclusion in this context refers to a penalty issued by Medicaid and the Office of Inspector General (OIG) to individuals involved in the health care industry who have been convicted of specified crimes. If an individual is excluded, he or she may not participate as a provider in any Federal health care program. In addition, excluded individuals may not be employed by any Federal health care program participant.

Who can be excluded?

Any individual or entity convicted of the specified crimes or misdemeanors. Excluded individuals may include MDs, PAs, RNs, LPNs, CNAs, and therapists, amongst a host of others.

How many types of exclusions are there?

There are two types of exclusions: Mandatory Exclusions and Permissive Exclusions.

Mandatory Exclusions are meted out as penalties for health care fraud/crimes; patient abuse; or unlawful distribution of controlled substances. The Office of Inspector General (OIG) is legally required to exclude individuals or entities convicted of such crimes for a minimum of five years. [42 U.S.C. § 1320a-7(a)]
Permissive Exclusions are mandated as penalties under 16 different authorities, and may be issued due to loss of state license to practice; failure to repay student loans; conviction of certain misdemeanors; failure to provide quality care; or one of several other misdemeanors. [42 U.S .C. § 1320a-7(b)]

Permissive exclusions are at the sole discretion of the OIG whether to place those guilty of misdemeanors related to federal or state healthcare programs under the LEIE. This includes reasons connected to professional competence, default in education loan obligations and financial integrity issues, among others.

How long do OIG exclusions last?

Mandatory exclusions can last depending on the number of offenses:[2]● Five years (1st offense)
● Ten years (2nd offense)
● Permanent exclusion (3rd offense)

Permissive exclusions, on the other hand, can last at the discretion of the OIG. Placement on the OIG Exclusion database could be anywhere between one to three years.[3]

Can those on the OIG Exclusion list (LEIE) charge federal healthcare programs for their goods or services?

No.  By law, Federal health care programs may not pay for any item or service furnished, ordered, or prescribed by an excluded individual or entity.  This prohibition includes prescriptions for medications, as well as administrative or management services provided by the excluded individual.

What is LEIE?
The LEIE stands for the List of Excluded Individuals/Entities. Those found on this OIG sanctions list may not perform services or provide goods related to Medicare, Medicaid or other healthcare programs.
How do you get out of the LEIE?
The only way is through a reinstatement procedure which is not automatic. Your period of exclusion may have already ended however you must still apply for reinstatement.

OIG Compliance Law

Laws and Publications on OIG Compliance

Section 1128 of the Social Security Act:

Exclusion of Certain Individuals and Entities

Section 1128 of the Social Security Act:

Exclusion of Certain Individuals and Entities

Section 1128B of the Social Security Act:

Criminal penalties for acts involving federal healthcare programs

Section 1156 of the Social Security Act:

Obligations of healthcare practitioners and providers

Center for Medicaid and State Operations

States must require providers to screen all employees and contractors monthly

General Publishing Office:

Effect of exclusion from participation in federal healthcare programs

General Publishing Office:

Denial of reinstatement if there is a violation of exclusion

Section 1862 of the Social Security Act:

Exclusions from Coverage and Medicare as secondary payer

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