OIG Exclusion List | Exclusion Screening Basics

OIG EXCLUSION LIST AND COMPLIANCE BASICS

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Understanding OIG Exclusions

1

WHAT IS OIG EXCLUSION AND WHAT IS THE LEIE?

The Office of Inspector General (OIG) is a department in the US federal government (the HHS) that is responsible for combating health care and Medicaid fraud. The OIG maintains an exclusion list, known as the LEIE or the List of Excluded Individuals and entities, which is continuously updated to include those who have abused or taken advantage of Medicare & Medicaid programs.

Any individual or entity listed on the LEIE cannot participate as a healthcare provider in any healthcare program funded by the federal government. A healthcare provider who is listed as an excluded individual in the OIG exclusion list and still practices medicine or any other form of healthcare can be fined, and sentenced with severe criminal charges. OIG excluded individuals and entities can include MDs, PAs, RNs, LPNs, CNAs, and therapists, among a host of others.

2

WHAT ARE THE DIFFERENT TYPES OF OIG EXCLUSIONS?

There are two types of exclusions: Mandatory Exclusions and Permissive Exclusions.
Mandatory Exclusions (with no discretion available from the OIG) 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 (with discretionary authority) 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)]

3

HOW LONG DO EXCLUSIONS LAST?

An individual recorded on the OIG exclusion list can remain there from a minimum of one year to an indefinite amount of time. Reinstatement as a qualified health professional is NOT automatic. Following the term of the exclusion, the OIG excluded individual must reapply for reinstatement and receive authorized notice that reinstatement has been granted.

4

CAN INDIVIDUALS ON THE OIG EXCLUSION LIST BILL FEDERAL HEALTH CARE PROGRAMS FOR SERVICES?

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

EMPLOYING AN EXCLUDED INDIVIDUAL

1

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.

2

CAN AN OIG FINE BE RESCINDED IF THE EMPLOYER WAS UNAWARE OF THE EMPLOYEE’S EXCLUDED STATUS?

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.

3

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 .

4

CAN AN EMPLOYER BE SUED FOR FIRING AN EMPLOYEE MISTAKENLY THOUGHT TO BE AN EXCLUDED INDIVIDUAL?

Yes. Verification mistakes can happen when an employee or potential hire is mistaken for an excluded individual with a similar name. The employer is responsible to verify that the employee or potential hire is, indeed, excluded .

OIG EXCLUSION SCREENING

1

WHAT IS OIG EXCLUSION SCREENING?

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

2

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 the status of each one of their employees. Various states require additional searches as well.

3

HOW IS AN EXCLUSION SCREENING SEARCH PERFORMED?

The employer inputs the employee’s (or potential hire’s) name and 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).

4

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.

5

HOW OFTEN MUST EMPLOYERS SCREEN THEIR EMPLOYEES FOR FEDERAL & STATE EXCLUSION STATUS?

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

6

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.

 OIG COMPLIANCE LAW

Exclusion of certain individuals and entities from participation in Medicare and state health care programs:

http://www.ssa.gov/OP_Home/ssact/title11/1128.htm

Criminal penalties for acts involving federal health care programs:

http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm

Obligations of health care practitioners and providers of health care services; Sanctions and Penalties; hearings and review

http://www.ssa.gov/OP_Home/ssact/title11/1156.htm

Publication of the OIG special Advisory Bulletin on the effect of exclusion from participation in federal health care programs

http://www.gpo.gov/fdsys/granule/FR-1999-09-30/99-25427

Exclusions from Coverage and Medicare as secondary payer

http://www.ssa.gov/OP_Home/ssact/title18/1862.htm

OIG can deny reinstatement to Federal Health Care Programs if there is a violation of exclusion

http://www.gpo.gov/fdsys/granule/CFR-2007-title42-vol4/CFR-2007-title42-vol4-sec1001-3002

CMS recommending the States require providers to screen all employees and contractors monthly

http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD011609.pdf