Federal laws require that all health care providers must verify that persons hired or contracted as a vendor are not excluded or sanctioned to participate in any Federal health care program.
Any claim that might involve an excluded person or entity could potentially have False Claims Act implications under the Affordable Care Act if it is not dealt with in a timely and proper manner.
OIG Exclusion Compliance
Federal laws require health care providers perform an OIG, SAM, LEIE, State Medicaid & Medicare Fraud exclusion sanctions screening of all employees and vendors. To help healthcare providers such as hospitals and physicians comply with relevant Federal health care laws and regulations, OIG creates compliance resources specific to various segments of the health care industry.
Office of Inspector General - HHS/OIG
OIG has the authority to exclude individuals and entities from Federally funded health care programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud. Those that are excluded can receive no payment from Federal healthcare programs for any items or services they furnish, order, or prescribe. This includes those that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).
Medicare, Medicaid and Tricare Fraud
OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
List of Excluded Individuals/Entities - LEIE
OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, health care entities should routinely check the list to ensure that new hires and current employees are not on it.
GSA - SAM
The Systems for Award Management (SAM) database provides four exclusion classifications: Firm, Individual, Vessel, and Special Entity Designation. It also uses four exclusion types: Ineligible (Proceedings Pending), Ineligible (Proceedings Completed), Prohibition/Restriction, and Voluntary Exclusion.
State Medicaid Exclusion Lists
In addition to the HHS OIG Exclusion List of Excluded Individuals and Entities (LEIE) and the GSA SAM, several states (plus the District of Columbia) have their own Medicaid Exclusion Lists. In addition to being excluded from the specific states in which a person or entity is listed, Section 6501 of the Affordable Care Act (ACA) mandates that if a provider or entity is excluded under any state Medicaid database, then that provider or entity should be excluded from participating in all states. State lists typically contain exclusions based upon licensing issues and many of these exclusions are not found on the LEIE, SAM or other state Lists.
In addition to these states excluded provider lists, many states also require providers to check other various Medicaid Exclusion databases. In Ohio, for example, providers must search the Ohio Department of Developmental Disabilities Abuser Registry, the Ohio Auditor of State – Finding for Recovery Database, Ohio Department of Developmental Disabilities Abuser Registry, Social Security Administration’s Death Master File, The National Plan, and Provider Enumeration System, in addition to the LEIE, SAM, and Ohio Exclusion List. New Jersey providers must check the LEIE, New Jersey Division of Consumer Affairs licensure databases, New Jersey Department of Health and Senior Services licensure database, and the certified nurse aide and personal care assistant registry on a monthly basis.
Provide employee or vendor name, date of birth and social security number. Our system allows for individual entry or batch upload with 100s or 1000s of names.
Our staff will process name in OIG, SAM, LEIE, State Medicaid & Medicare exclusion, and sanctions databases.
If a possible match is found, we escalate to quality assurance for further verification. If no match is found, we proceed to post “No Records Found” for your search request.
To filter false positive exclusion screening results, we further verify records against your search subject’s social security number for a 100% match score. It is then posted to your account with an alert flag.
Exclusion Screening Report
Rest assured, We have you covered.
Federal health care programs, principally Medicare and Medicaid, will not pay for any item or service that is furnished or performed by, or on the prescription or direction of, an excluded individual. Since federal health programs subsidize virtually all hospitals and account for 60-65% of all health care dollars spent, exclusion is a severe restriction and is often a death knell to providers.
Providers of the federal health care programs must ensure that their employees, contractors, and vendors are not excluded and the failure to do so can result in significant penalties. The OIG has the authority to impose penalties of up to $21,562.80 for each item or service furnished by the excluded person or entity, as well as assessments of up to three times the amount claimed. In addition, providers may be liable for overpayments.