An In-Depth Look at The OIG Exclusion List
The OIG Exclusion List is the Foundation of Provider Screening
The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) oversee the reimbursement of health care providers who serve beneficiaries of federally funded programs. The Department of Health and Human Services Office of Inspector General (OIG) maintains and enforces the OIG List of Excluded Individuals and Entities (LEIE). The HHS OIG is charged with identifying and combating waste, fraud, and abuse in all HHS programs to protect the integrity of these programs and the well-being of its beneficiaries.
HHS OIG is the largest inspector general’s office in the Federal Government, with approximately 1,600 employees dedicated to combating fraud, waste, and abuse and to improving the efficiency of HHS programs. Most of OIG’s resources go to overseeing Medicare and Medicaid – programs that represent much of the Federal budget and affect the most vulnerable U.S. citizens.
HHS OIG oversees more than 300 HHS programs including Medicare, Medicaid, TRICARE, and CHIP. Federal reimbursement, whether direct or indirect, for goods provided or services rendered by an excluded individual or entity, is prohibited. OIG holds accountable those who bill Medicare or Medicaid but do not meet Federal health program requirements.
OIG’s List of Excluded Individuals and Entities (LEIE)
The OIG exclusion list database, the List of Excluded Individuals and Entities (LEIE) is updated monthly and contains the current list of excluded individuals and entities. Individuals and entities are added to the LEIE due to offenses related to health care fraud or abuse. The LEIE exists to assist health care organizations who bill federally or state-funded programs to maintain compliance and avoid penalties and fines associated with excluded providers. Health care organizations are required to check all new hires and contractors, as well as regularly monitor the LEIE to assure there are no services or items rendered by and/or reimbursed on behalf of an excluded individual or entity.
How Does the OIG Exclusion Process Work?
For some mandatory and most permissive exclusions, OIG will send a written Notice of Intent to Exclude (NOI) to individuals or entities that they are considering excluding. The NOI includes the specifics for the proposed exclusion as well as potential effects to the provider or entity if excluded. The NOI allows the individual or entity 30 days to respond in writing with any evidence or information relevant to the proposed exclusion. OIG will review all provided information before making a final decision about whether or not to impose the exclusion.
When an individual or entity receives an NOI, it does not necessarily mean they will be excluded. In some mandatory exclusion cases, an NOI is not sent and the individual or entity receives a Notice of Exclusion as their initial notification.
What is the Appeals Process for an OIG Exclusion Notice?
The non-compliant individual or entity who receives a Notice of Intent to Exclude (NOI) can appeal the action to an HHS Administrative Law Judge (ALJ) and from there, an adverse decision can go on to be appealed to an HHS Departmental Appeals Board (DAB). In some cases, a judicial review in Federal court is available after a final decision has been made by the DAB.
What is the Difference Between a Mandatory and Permissive OIG Exclusion?
Mandatory OIG exclusions, enforced for a minimum of 5 years, are imposed for the following reasons:
- Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, CHIP, or other State health care programs
- Patient abuse or neglect
- Felony convictions for other health care related fraud, theft, or other financial misconduct
- Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances
Permissive OIG exclusions are typically imposed for 1 – 3 years. Here are some of the reasons for a permissive exclusion, though this is not an exhaustive list:
- Misdemeanor convictions related to health care fraud other than Medicare or a State health program
- Fraud in a program (other than a health care program) funded by any Federal, State, or local government agency
- Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
- Suspension, revocation, or surrender of a license for failure to provide health care for reasons bearing on professional competence, professional performance, or financial integrity
- Provision of unnecessary or substandard services
- Submission of false or fraudulent claims to a federal health care program
- Engaging in unlawful kickback arrangements
- Defaulting on health education loan or scholarship obligations
- Entities controlled by a sanctioned individual such as an owner
- No Federal health care program payment may be made for any items or services furnished by an excluded individual or at the medical direction or on the prescription of an excluded provider.
- This applies to the individual even if they change from one health care profession to another while excluded.
- This payment prohibition applies to excluded individuals who work for or under an arrangement with a hospital, nursing home, home health agency, or managed care entity.
- Payment prohibition also applies to services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling prescriptions for drugs that are billed to a Federal health care program.
- Excluded individuals are prohibited from providing transportation services that are paid for by a Federal health care program, such as those provided by ambulance drivers or ambulance company dispatchers.
What are the Penalties for Services Provided by an OIG Excluded Individual?
Those who file for Federal reimbursements for services or items provided by an excluded individual or entity are subject to entering into a Corporate Integrity Agreement, fines, or civil monetary penalties.
Penalties for services provided by an excluded individual can include:
- $10,000 – $20,000 per each item claimed or services provided
- Treble damages (3 times the amounts claimed to CMS for reimbursement)
- Possible program exclusion of the organization
- Possible loss of the right to bill CMS for services rendered
- Possible additional fines for filing false claims under the False Claims Act (Penalties up to $11,000 per claim, and possible placement in a Corporate Integrity Agreement with the OIG)
- Possible criminal fines and/or jail time
What is the OIG Exclusion List Reinstatement Process?
The OIG has the authority to reinstate LEIE listed individuals or entities if they meet the necessary requirements.
Excluded providers may begin the process of requesting reinstatement 90 days before the end of their excluded period. For those who fall under a mandatory OIG exclusion, the designated exclusion period is listed in their notification letter. The time that an exclusion applies can vary widely depending on the type of exclusion and what criteria have to be met to apply for reinstatement.
Reinstatement does not automatically happen at the end of an individual’s excluded period. Here are the steps to apply for reinstatement:
- Draft a written request which contains the following:
- Individual’s or entity’s full name (if excluded under a different name, also include that name)
- Date of birth for an individual
- Telephone number
- Email address
- Mailing address
- Fax or email the request to the OIG at (202) 691-2298 or firstname.lastname@example.org.
- If eligible, the OIG will send statement and authorization forms. Fill them out with the proper notarization and return them.
Once the statements and authorization forms have been evaluated by the OIG, they will send a written notice of reinstatement or denial. This is a lengthy process and can take up to 120 days or more. If a provider is on a State Medicaid Exclusion list and on the OIG LEIE they must apply for reinstatement to each list separately. State exclusion authorities do not remove providers from their lists based on the individual being reinstated at the Federal level. They must follow the reinstatement process for both state and federal lists.
What are the Challenges in Provider Exclusion Screening?
- Rate of turnover of providers and staff within an organization
- Accurate identity matching using all former names/maiden names
- State hopping by providers to avoid detection
- Self-reporting by providers
- Continual updates to both the state and federal databases
- Delays in reporting from states to federal lists
Best Practices in Exclusion Screening
The exclusion monitoring process is very complicated and time-intensive. Among health care organizations there exist varying levels of provider screening and exclusion monitoring. Many organizations conduct exclusion screening and monitoring in their own unique way. Some only check federal databases such as OIG LEIE and SAM to screen their providers. Others take it a step further and check federal exclusion lists for providers plus staff, entities, and vendors. Some organizations check the OIG LEIE and SAM exclusion lists plus State Medicaid Exclusion lists for their providers but don’t screen additional staff, entities, and vendors against the state exclusion lists.
Industry best practice is to screen all providers, staff, entities, vendors, and owners against all federal and state exclusion lists for exclusions, sanctions, debarments, and disciplinary actions and then monitor these lists on a monthly basis.
Both federal and state exclusion lists need to be routinely checked. There are 42 State Medicaid Exclusion lists. States are required to report exclusions or terminated Medicaid providers to HHS OIG within 30 days. Health care organizations need to check every state exclusion list in addition to OIG LEIE and SAM. Organizations that bill Federally or state-funded programs must monitor their providers, employees, vendors, entities, and owners for exclusions each month.
Exclusion by the OIG from one program means exclusion from all HHS programs (pursuant to sections 1128 and 1156 of the Act). Furthermore, under the Affordable Care Act, an individual or entity excluded in one state is not permitted to participate in federal health care funds in all other states.
There are other screening and monitoring data points that give early warning signs to an impending exclusion. For instance, hiring a provider who is not listed on the LEIE, but is engaged in the exclusion appeals process will likely appear on the Department of Justice’s database, or a State Attorney General’s list, or any number of primary sources that publish felony and misdemeanor criminal records. Individual licensing boards can also be checked for information about sanctions and disciplinary actions.
Protecting your organization and the patients it serves requires a proactive approach. Implementing a thorough screening and continuous monitoring program using aggregated data from multiple primary sources will help you steer clear of those on the brink of exclusion or from those who are excluded and intentionally evade detection.
Verisys Offers Up-to-date, Continuous Monitoring of all State and Federal Exclusions
CheckMedic® OIG exclusion monitoring is Verisys’s data technology platform tapping its proprietary data set of exclusions, sanctions, debarments, and disciplinary actions. Additionally, FACIS®, the most comprehensive data set for screening and monitoring health care providers, is continuously being updated. Verisys teams pull data from more than 5,000 data sources, adding roughly 75,000 records to the FACIS database each month. With one login, an organization can automate continuous exclusion monitoring and set alerts to receive notice of adverse action affecting one of your providers.
The OIG exclusion list is a vital source to check when screening and monitoring your provider population, but it does not provide enough information to have a complete picture of compliance. Using FACIS provides that complete picture. Taking the extra measure to check thousands of additional data sources protects your organization from financial and reputational risk and increases patient safety.
|Written by Juliette Willard
Healthcare Communications Specialist
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