Current States With Separate Exclusion Databases



I. Medicaid Exclusion

Exclusion Screening, LLC conducts monthly checks of our clients’ employees, contractors, and vendors against the OIG-LEIE, GSA-SAM, and all available State Exclusion Lists. Most providers understand that they have an obligation to check their employees, contractors, and vendors against the OIG-LEIE prior to hiring and monthly thereafter. Fewer providers are aware of their obligation to screen their individual state exclusion list, if their state maintains such a list.

CMS directed state Medicaid Directors to remind all providers that they have an obligation to search their state list whenever they search the LEIE.[1] In addition, many states require providers when they enroll or re-enroll in the Medicaid program to certify that no employee or contractor is excluded from participation in any state. This requirement echoes the Affordable Care Act (ACA) Section 6501, which states that if a provider is excluded in one state, he or she is excluded in all fifty states.[2]

II.  SAFERTM 

Exclusion Screening, LLC’s proprietary database, SAFER (State and Federal Exclusion Registry), imports the most recent exclusion data from each state list constantly. We are also in regular contact with state Medicaid and Program Integrity Offices about their lists.

III. State Exclusion Lists

The states that currently maintain a separate excluded provider list are the following ones below, click on a state to learn more about its screening requirements: 

AlabamaIdahoMichiganNorth Carolina
AlaskaIllinoisMinnesotaNorth Dakota
ArizonaIndianaMississippiOhio
ArkansasIowaMissouriPennsylvania
CaliforniaKansasMontanaSouth Carolina
ColoradoKentuckyNebraskaTennessee
ConnecticutLouisianaNevadaTexas
FloridaMaineNew HampshireWashington
GeorgiaMarylandNew JerseyWashington DC
HawaiiMassachusettsNew YorkWest VirginiaWyoming

IV.  Some States Require Screening Extraneous 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.[3] 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.[4] 

For additional information visit “OIG Exclusion and State Exclusion Lists: Which Exclusion Lists Need to Be Screened? What Is the Difference Between Them?”
V.  A Simple and Affordable Solution

Without a doubt, state and federal exclusion screening requirements are incredibly burdensome for most providers. If screening your employees against each federal and state list that your state requires is not cost effective for your office to do in-house, contact Exclusion Screening, LLC today at 1-800-294-0952 or fill out our online service form. We would be happy to discuss your specific state obligations, provide a cost assessment, and help you create your employee and vendor list.

Medicaid oig Exclusion

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.


[1] See Letter from Centers for Medicare and Medicaid Services (CMS) to State Medicaid Directors 5 (Jan. 16, 2009).

[2] See 42 U.S.C. § 1396a(a)(39) (2012), available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf (codifying the termination requirements of ACA § 6501); see also Letter from Centers for Medicare and Medicaid Services (CMS), CPI-CMS Informational Bulletin, Affordable Care Act Program Integrity Provisions – Guidance to States — Section 6501 – Termination of Provider Participation under Medicaid if Terminated under Medicare or other State Plan (Jan. 20, 2012), available at http://downloads.cms.gov/cmsgov/archived-downloads/CMCSBulletins/downloads/6501-Term.pdf.

[3] See Ohio Admin. Code § 5160-1-17.8(c)(ii); Ohio Medicaid Provider Exclusion and Suspension List, Ohio Dep’t of Medicaid, http://medicaid.ohio.gov/PROVIDERS/EnrollmentandSupport/ProviderExclusionandSuspensionList.aspx (last accessed Jan. 22, 2015).

[4] Newsletter to All Providers, from the New Jersey Dep’t of Human Servs., et al., Excluded, Unlicensed or Uncertified Individuals or Entities (Oct. 2010).

OIG Exclusion and State Exclusion Lists: Which Exclusion Lists Need to Be Screened? What Is the Difference Between Them?

oig exclusion list

There are two federal databases that list persons and entities that have been excluded from participating in federal health care programs or receiving federal contracts. Checking and verifying individuals on the OIG Exclusion List of Excluded Individuals and Entities (LEIE) and the GSA System for Award Management (SAM) should be part of any compliance exclusion screening program. The LEIE is maintained and updated by the Office of Inspector General for the Department of Health and Human Services (HHS-OIG), and the SAM consolidates several procurement based databases. 

Many states (over 40 as of today) also have their own individual databases which list individuals and entities that have been excluded from participating in their State Programs (such as Medicaid) or receiving any State contracts. We’ll briefly discuss the difference between these exclusion lists and explain why each should be screened. 

I.  OIG Exclusion List (LEIE)

oig exclusion list

The OIG exclusion list, LEIE, is maintained specifically for the purpose of listing all persons and entities that have been excluded from participating in the Medicare program. It is comprised of all persons currently excluded from the program by the OIG and is updated monthly. The list contains the name of the excluded individual or entity at the time of the exclusion, the provider type, the authority under which the individual was excluded, and the state where the excluded individual resided at the time of the exclusion. The LEIE can be accessed on the OIG’s website and up to five names can be searched at a time. It can also be downloaded for searching purposes. Matches can then be verified individually by Social Security Number.

It is important to remember that the LEIE is prepared and maintained by HHS for the specific purpose of identifying persons or entities that have been excluded from the Medicare Program by its Inspector General. Therefore, it will not contain persons or entities on other exclusion lists if, for instance, the information was never forwarded to it, or if the basis of that exclusion was insufficient to support one from the LEIE.[1]

II.  GSA-SAM

oig exclusion list

The SAM is an attempt by the federal government to consolidate several pre-existing procurement systems and combine them with the Catalog of Federal Domestic assistance. It is being done in phases. The first phase combined the functionality of the systems that listed persons or entities that were debarred, sanctioned, or excluded for contract or other fraud into a single searchable exclusion database. These were the Central Contractor Registry (CCR), Federal Agency Registration (FedReg), Online Representations and Certifications Application (ORCA), and the Excluded Parties List System (EPLS).

The SAM uses 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.[2] There is significant overlap between the SAM and the LEIE. However, they were both created by several different agencies, and each has its own specific administrative process. It is not surprising that there are large gaps between them, and that they are ultimately very different in composition.

III.  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. These states are identified in red in the map to the left. 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.[3] 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. This occasionally occurs because the exclusion is based on a violation of a particular state statute. It also occurs because many states have inadequate processes to communicate exclusions to either the Federal Databases or their sister states.

Click below to learn more about the Exclusion Screening requirements in your State!
AlabamaIdahoMichiganNorth Carolina
AlaskaIllinoisMinnesotaNorth Dakota
ArizonaIndianaMississippiOhio
ArkansasIowaMissouriPennsylvania
CaliforniaKansasMontanaSouth Carolina
ColoradoKentuckyNebraskaTennessee
ConnecticutLouisianaNevadaTexas
FloridaMaineNew HampshireWashington
GeorgiaMarylandNew JerseyWashington DC
HawaiiMassachusettsNew YorkWest VirginiaWyoming
IV. Conclusion

The OIG exclusion list LEIE, (GSA) SAM, and State Medicaid databases were all created by different entities for different reasons. They have different exclusion criteria and though they address concerns that may be similar in nature, the information is often agency specific. Ultimately, the lists often contain different entities and persons. Considering these differences and the severity of the risk of employing excluded persons, we strongly recommend conducting monthly searches of all of these databases. Contact the exclusion experts at Exclusion Screening, LLCSM by calling 1-800-294-0952 or fill out our online service form.

Ashley Hudson

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. 


[1] For more information see other discussions within our site on the effects of exclusion and the publication by the U.S. Dep’t of Health and Human Servs. Office of the Inspector Gen., Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, 13 (May 8, 2013).

[2] When EPLS was consolidated into SAM in July 2012 Cause and Treatment (CT) codes were eliminated. For more information on the transformation see Changes from EPLS to SAM on the SAM website at https://www.sam.gov/sam/transcript/Quick_Guide_for_Changes_From_EPLS.pdf.

[3] 42 U.S.C. 1396(a) (2012). Whether an exclusion by one state actually “excludes” an individual from all states or makes him “excludable” from all states is an open question at present, but why take the chance of hiring a person who has been excluded in another State if you don’t have to?

Who Is to Blame for Gaps in OIG and State Exclusion Lists? What Is the Impact on Providers?

 

The failure to report excludable offenses by state Medicaid offices and licensing boards is a longstanding issue for the OIG. Recent OIG audits and reports have confirmed these state failures to report. For example, an OIG study released in August found that over 12% of terminated providers were able to continue participating in other state Medicaid programs because states were not sharing terminated provider information. In addition, two recent Medicaid Fraud Control Unit (MFCU) audits discovered that they routinely failed to timely report conviction information to the OIG and sometimes did not report them at all.[1] Reporting failures lead to gaps in the OIG Exclusion List (LEIE) because the OIG cannot exclude an individual if the OIG is never informed of the state’s conviction, termination, or suspension of providers. Such failures to report are important because the information that would have been reported can lead to exclusion violations, which are listed on the LEIE. But, state compliance failures are not the only cause of gaps in OIG and State exclusion lists – as we discuss, no matter who is at fault, the provider may pay for anyone’s mistake.

The OIG Exclusion List Has Limited Search Capabilities

One important reason providers should not rely on screening only the LEIE is that its search function is extremely narrow.  If an excluded individual uses a different name, such as a middle or maiden name, an LEIE search using the person’s first and last names my not produce any results.[2]  For example, J. A.[3] was excluded from participation on Georgia’s state exclusion list in August 2015. However, a search for “J.A.” on the LEIE currently produces zero results. 

J.A. LEIE_Redacted

Conversely, when we searched J.A. on SAFERTM, our proprietary exclusion database, we not only found a match on the Georgia list (“J.A.”), but we also found a match on the LEIE and SAM databases for “R.J.A.”. Interestingly, “J.A.” has the same middle and last name as “R.J.A.,” they are both Georgia residents, and they were both excluded from participation in April 2015. Like many states, the identifying information on Georgia’s list is sparse. Nevertheless, it is extremely likely that R.J.A. and J.A. are the same person, which a provider would have missed if he only searched the LEIE for J.A.

J.A.SAFER_Redacted

Reported Cases May Not Be Picked Up by OIG

Florida’s Agency for Health Care Administration publishes monthly press releases which identify persons terminated from participation in Florida Medicaid.  It expressly states that the exclusion information was “reported to the federal government for placement on the federal exclusion list,” and named providers appear on Florida’s Excluded Provider List.  When we conducted a SAFERTM search for G.B., who was listed on the April 2015 memo as “terminated from participation,” the only two “hits” were from Florida’s state exclusion list.  

G.B. SAFER_Redacted

However, an LEIE search for G.B. produced zero results.  

G.B. LEIE_Redacted

One possible explanation for why G.B. fails to show up on the LEIE could be the administrative process of OIG actually reviewing the reason for the termination and then formally excluding G.B. Nevertheless, a provider who only screens the LEIE and employs or is considering employing G.B. would miss this exclusion.  

OIG Just Misses Some Cases

K.B., a Registered Nurse (RN) with multistate licensure privileges, was placed on probation for substance abuse in February 2005. After testing positive for morphine, Iowa revoked her license and several other states revoked her multistate privileges. While the revocations were reported, the licensure revocation only resulted in K.B.’s exclusion from participation by California and the GSA-SAM in 2010. K.B. is not listed on the LEIE. This means that K.B. is unable to participate in any other state Medicaid program because under the ACA 6501, if you are terminated for cause from participation in one state, then you are terminated in all states, and K.B. is barred from contracting with the federal government. However, if a provider only screened the LEIE he would be completely unaware and could potentially face very hefty fines.

What This Means

Clearly some information is getting lost or mixed up in the reporting pipeline between state Medicaid offices, MFCUs, and the OIG, and the lesson for providers is that merely screening the LEIE is not enough. The examples above demonstrate that human error, narrow search functions, and simply missed information all play a role in the gaps that exist between publication on state exclusion lists and the LEIE.

State Medicaid offices are responsible for compiling and reporting information about excluded providers. However, as demonstrated by the “J.A.” case, the probable human error of transposing names combined with the LEIE’s limited search capabilities could result in a provider employing an excluded person, even though he was properly screened against the LEIE. To avoid this, providers should screen against the LEIE, the GSA-SAM, and all available state lists monthly. Practices should also ensure they use wide search parameters (alternate spellings, full names, maiden names, etc.) when conducting searches or they should select a vendor, like Exclusion Screening, LLC, with a system designed to anticipate these issues.

Notwithstanding name discrepancies, some information just does not make it to the LEIE. As the “G.B.” example reveals, a practice may face considerable monetary fines because it failed to screen the Florida exclusion list and relied solely on the LEIE for exclusion information, and the OIG failed to add G.B.’s name to the LEIE. Similarly, a provider who considered employing “K.B.” would be totally unaware that she was excluded from participation unless the provider screened the GSA-SAM and/or the California exclusion list. Remember that ACA section 6501 states that when an individual or contractor is excluded in one state, he or she is excluded in all states. When a provider misses such state exclusion information, he or she could be liable for CMPs of $10,000 for each claim provided directly or indirectly by the excluded individual, an assessment of up to three times the total amount paid by the government, and potential false claims liability.  Relying on the LEIE’s exclusion information without checking all other available state exclusion lists is a substantial monetary risk for a practice to take. If screening and verifying 40 state and federal exclusion lists each month is overly burdensome for your practice, contact Exclusion Screening, LLC today for a free assessment: 1 (800) 294-0952.

[1] MFCUs are supposed to send a referral letter to the OIG within 30 days of sentencing for the purpose of alerting the OIG about providers excluded from state programs, but the OIG found that in some cases this exclusion information was not referred to the OIG for over 100 days.

[2] We have even found that hyphenated names frustrate LEIE searches even where the actual names are used!

[3] Full names have been redacted for privacy.

DOJ Files Another False Claims Act Case Based on OIG Exclusion Violations

oig exclusion violations

DOJ Pursuing Action on Two Separate OIG Exclusion Violations

The U.S. Attorney’s Office in Philadelphia filed a False Claims Act case last week based primarily on OIG exclusion violations. The complaint alleges that the defendant filed several documents concealing his exclusion and his role in Mental Health Clinics ostensibly run by his wife. Medicare and Medicaid do not pay for services provided, either directly or indirectly, by someone who is on the OIG List of Excluded Individuals (LEIE) or on a State Medicaid Exclusion List. The lawsuit comes on the heels of a suit with similar allegations brought by that office in May. It further evidences the increasing interest of OIG and DOJ in enforcing exclusion regulations and exclusion screening requirements.

The filing was announced by United States Attorney Zane David Memeger. He stated that, “this civil complaint reflects our focus on pursuing individuals who defraud Medicaid and Medicare, especially after they have previously defrauded those programs and been barred from participating in them.” The complaint also alleges fraudulent billing for services provided without proper supervision and by unqualified persons.

While both cases involve similar fact patterns (persons concealing their exclusion status and involvement in a company) and were filed within months of each other, it is significant to note that they arose in completely different ways. The most recent case’s complaint is a whistleblower lawsuit that was brought to the government by an ex-employee. The older case, however, arose from an OIG led investigation.

Final Thoughts

There are two clear takeaway points from these cases. First, exclusion violation enforcement cases can come to the attention of the government in several different ways. Second, the DOJ, OIG and CMS have a number of different enforcement options at their disposal! So remember, compliance is always the best option!

Read more on OIG Exclusion

OIG Exclusion

Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime health care lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should you have any  questions at: pweidenfeld@exclusionscreening.com or 1-800-294-0952.

Unlocking the GSA-SAM Mystery

server room GSA-SAM SAM Exclusion Search

I. SAM Exclusion Search

We talk fairly infrequently about the General Service’s Administration’s System for Award Management (GSA-SAM) and about SAM Exclusion Search and thought it was time to address that lapse in information!

We know that the Office of the Inspector General has authority to exclude individuals under Section 1128 of the Social Security Act. It is also true that many individuals who appear on the SAM were originally listed on the Excluded Parties List System (EPLS). In addition, the SAM includes information from the Central Contractor Registration System (CCR) and the Online Representations and Certifications Application (ORCA). Now that these lists have merged, we wondered where the SAM was getting its updated exclusion information from.

II. The Agencies Reporting Exclusions to the GSA-SAM

If you have reviewed the SAM, you may have noticed that different agencies are listed along with excluded individuals. As of April 21, 2015, 68 federal agencies were reporting exclusions to SAM including the Department of Health and Human Services (HHS), the Department of Justice (DOJ), Veteran’s Affairs (VA), and the Department of Agriculture (USDA).

One of our favorite activities is getting into the weeds of an exclusion database, so our experts took a closer look at the agencies that were reporting to SAM. We discovered that over half of the total exclusions reported to SAM come from HHS. This was expected because we often find that if a name matches a person on the LEIE it also matches a person on the SAM. The next largest contributors were: the Office of Personnel Management (OPM) (26.6%); the Department of the Treasury Office of Foreign Assets Control (TREAS-OFAC) (6.2%); the Department of Justice (DOJ) (5.2%); and the Department of Agriculture Office of Food and Nutrition Services (USA-FNS) (3.1%).

Because OPM is the next largest reporting agency, we looked into who is excluded under its authority. OPM is also excludes health care providers. Specifically, it is debars them from participation in the Federal Employees Health Benefits Program (FEHBP). This means that 77.4% of the persons excluded on the SAM are excluded from participating from some health care industry component.

III.  Final Thoughts

This discovery supports our belief that it is critical to screen the SAM in addition to the LEIE.  OPM excludes from FEHBP individuals who have lost a professional license, been convicted of a crime related to the delivery of or payment for health care services, violated provisions of a Federal program, or been debarred by another Federal agency. These reasons mirror some of the reasons individual and entities are excluded from participation in the Federal health care programs by OIG and State Medicaid offices. It is likely that individuals excluded by OPM will also be excluded by the OIG, but there is no way to know how often information passes between these agencies or between licensing boards and the agencies. 

In our opinion, best practices include screening the SAM and the LEIE monthly, in addition to all available state lists, to ensure that your office is protected and potentially knows about an excluded individual before the OIG. Exclusion Screening, LLCSM conducts a comprehensive search of all available databases each month for its clients. For a free consultation, please call 1-800-294-0952 or fill out our assessment of needs and costs.

Ashley Hudson SAM Exclusion Search

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. Contact the exclusion experts at Exclusion Screening, LLCSM today for a free consultation by calling 1-800-294-0952 or online.

2014 In Review – OIG Crack Down on Exclusion Violations

OIG Exclusion Violations

I.  CMPs doubled in OIG Exclusion Violations 2014

Exclusion Screening, LLCSM dedicates a significant amount of time to examining the Office of the Inspector General’s (OIG) enforcement actions as they relate to exclusion violations. As a broad overview, in 2014 HHS-OIG imposed $10.54 million in Civil Monetary Penalties (CMPs) on providers that “knew or should have known” one or more of their employees or vendors was excluded from participation in the Federal health care programs. Most noteworthy, this number more than triples the $3.26 million in CMPs collected in 2013 and is the highest amount collected in the last five years.

In 2014, the OIG cracked down on many different types of providers. The OIG’s focus varied from pediatricians to large hospitals to home health organizations. However, the OIG specifically targeted nursing homes, which totaled a quarter of all exclusion enforcement actions in 2014. While nursing homes were also the most highly targeted industry in 2013, the OIG doubled the number of enforcement actions against nursing homes for exclusion violations in 2014.

II.  2015 Likely to See Increase in OIG Enforcement Action

Do these higher CMP amounts and increased enforcement actions mean there were simply more bad actors in 2014 than 2013? Likely no. These increases indicate that the OIG has identified an area ripe with exclusion violations and chose to target this sector. In fact, in its 2015 Work Plan, the OIG specifically mentions that fraud is prevalent in home health agencies and pledged to determine the extent to which home health agencies are employing individuals with “potentially disqualifying” criminal convictions. 

Are specific areas of the United States more vulnerable than others for exclusion related violations? No. In fact, the OIG enforcement actions are not localized to one particular state or geographic area. The 60 exclusion enforcement actions in 2014 spanned 32 states. Texas took the lead with 6, and California followed closely with 5. Utah, North Carolina, and Ohio each had 4 enforcement actions. Furthermore, smaller states like Vermont and Iowa were not far behind with 3 and 2 enforcement actions.

III.  Monthly OIG Exclusion Screening Is Essential

From this data, we can conclude that no matter the size, location, or industry, providers and health care organizations must be checking all their employees and vendors for exclusions against the LEIE, SAM, and state lists monthly. The OIG is not slowing down enforcement of exclusion violations. The OIG posted its first exclusion action of 2015 with a CMP collection of $431,041.28 for one excluded employee. Conducting proper screening may seem burdensome, but Exclusion Screening, LLCSM can help your practice comply with state and federal exclusion screening obligations at a low, fixed price. Contact us for a free consultation at 1-800-294-0952 or fill out our online service form today.

Also read more on OIG Exclusion

OIG Exclusion Violations 2014

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.

Why Should I Screen Against Every State Exclusion List?

man overwhelmed by paper - state exclusion list

The Office of the Inspector General (OIG) issued a Special Advisory Bulletin in May 2013, which states that providers can “avoid potential Civil Monetary Penalty (CMP) liability” simply by checking the List of Excluded Individuals and Entities (LEIE) to “determine the exclusion status of current employees and contractors.” This past fall, September – November 2014, OIG collected $1.54 Million in Civil Money Penalties (CMPs) in cases involving the employment of persons that have been “excluded” from Medicare.

These providers were held liable because they “knew or should have known” that an employee or contractor was excluded from participation in the Federal health care programs. The “knew or should have known” standard arises from the same 2013 OIG Special Advisory Bulletin. OIG states that because the LEIE is updated monthly, so OIG recommends that providers check their employees and vendors against the LEIE and SAM monthly in order to avoid CMP liability.  The CMPs a provider may face for employing or contracting with an excluded individual or entity include liabilities of $10,000 for each item or service furnished directly or indirectly by an excluded individual, in addition to an assessment of up to three times the total damages, and exclusion from participation in the Federal health care programs.

In addition to the federal lists, thirty-six states now have their own excluded provider lists.  These states require, at a minimum, that providers check their employees and contractors against their state list in addition to the LEIE as a requirement to participate in Medicaid and other state health care programs like SCHIP.  State mandates to search are hidden in a variety of documents such as Medicaid Provider Applications and Agreements, Disclosure of Ownership Interest, the State Code, or even the State’s Excluded Provider List.

At Exclusion Screening, LLCSM, we recommend screening your employees and contractors against not only the federal lists and your state’s list, but every available state list. The reason we recommend screening your employees against every available federal and state list is simple.  Do you want a person another state has determined is not permitted to bill to their Medicaid or SCHIP program working for your practice? A majority of individuals, at least according to the LEIE, are excluded because his or her license was revoked.  Other reasons include felony and misdemeanor convictions for committing health care fraud or for controlled substance offenses. 

As of December 2014, 26,178 individuals, or nearly half of the total individuals and entities excluded from participation in the Federal health care programs on the LEIE, were excluded due to a license revocation.  An immediate concern following this statistic is that, according to Deputy Inspector General for Investigations Gary Cantrell, not all state licensing boards provide information regarding adverse action taken against providers to OIG.  Cantrell reported to House Subcommittee on Oversight and Investigations within the Committee on Energy and Commerce, that States are not required to provide this information by statute leaving the OIG with incomplete exclusion information.

Furthermore, the under ACA Section 6501, all states are required to deny or terminate enrollment of any provider that is terminated “for cause” by Medicare or another State’s Medicaid or SCHIP program.  While the parameters of this new mandate are not yet flushed out, we believe that it is good practice to stay ahead of OIG when it comes to exclusions.  Under an ACA sister provision, 6401(b)(2), the Centers for Medicare and Medicaid Services (CMS) was required to create a national database where State agencies could share and access information about individuals and entities that were terminated from the Medicare, Medicaid, or SCHIP programs.  CMS created the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS) to make this information available to all State Medicaid agencies so that other states could identify providers that needed to be terminated.

Even though CMS had the authority to require states to submit this information, it only asked states to comply; CMS’s failure to make reporting mandatory resulted in a very deficient database with only 33 states submitting information, most of which was incomplete.  After two years of insufficient reporting, CMS discontinued the MCSIS database.  It plans to create a new private database, but CMS has not provided a proposed completion date for this new OnePI system or stated whether it would share information with the OIG-LEIE.

Additionally, some states have imposed their own strict requirements on providers.  Louisiana providers are required to check the LEIE, SAM, and the Louisiana Department of Health and Hospital Adverse Actions website upon hire and monthly thereafter for all employees and or subcontractors.  Louisiana providers are required to maintain proof in their records that these monthly checks were done for employees and or subcontractors, which may be evidenced by printing out search results. Providers are required to check all current and previous names  including first, middle, maiden, married, or hyphenated names and aliases for all owners, employees, and contractors.  If a provider learns an employee or subcontractor is excluded after hiring, the provider must notify the Department of Health and Hospitals within ten working days.

Texas, like Louisiana, requires that before a provider submits a Medicaid enrollment application, “the applicant or re-enrolling provider must conduct an internal review to confirm that neither the applicant or the re-enrolling provider, any of its employees, owners, managing partners, or contractors, have been excluded from participation” in Medicare, Medicaid, or SCHIP. In addition, Texas requires that an applicant or re-enrolling provider must also not be terminated from participation in another state’s medical assistance program or SCHIP. Texas Medicaid providers are responsible for checking the LEIE monthly and the Texas Medicaid Excluded Provider (HHSC) list upon hiring and periodically thereafter.  While Texas does not define periodically, it does remind providers that they are liable for all fees paid to them by Texas Medicaid for services provided by excluded individuals and “strongly recommend[] that providers conduct frequent period checks of the HHSC exclusion list.” The list is updated weekly.

Ohio also has a unique set of requirements.  Ohio Medicaid providers must, according to the Medicaid Provider Agreement, certify that he or she has no employment, consulting, or any other arrangement with excluded individuals or entities.  Managed Care Programs must, at a minimum on a monthly basis, search for excluded providers on the LEIE, the Ohio Department of Job and Family Services (ODJFS) Excluded Provider Page, and the applicable discipline pages of state boards that license providers.  Ohio providers are also required to search the SAM, the Ohio Department of Developmental Disabilities Abuser Registry, and the Ohio Auditor of State.

In addition to various state requirements, private health care companies also have begun including exclusion screening requirements.  Aetna, for example, requires that all health care professionals verify that all employees and “downstream entities that perform administrative or health care services to Aetna’s Medicare Plans” are not excluded on the LEIE or SAM.  If an Aetna provider discovers it has employed or contracted with an excluded provider, then he or she must immediately remove this individual or entity from Aetna related work and immediately notify Aetna.  Humana has nearly identical provisions for their physicians, hospitals, and other health care providers.

Screening employees for exclusions has morphed from an easy compliance responsibility to an overbearing obligation.  “Knew or should have known” is an easily manipulated standard.  Should you have known that another state excluded one of your employees or contractors? If OIG thinks so, you will be liable for Civil Monetary Penalties of up to $10,000 for each item or service furnished directly or indirectly by the excluded individual or entity, an assessment of up to three times the total damages, and exclusion from participation in the Federal health care programs. OIG has ramped up its exclusion enforcement evidenced by CMP liabilities resulting from self-disclosures and investigations totaling 6.07 million dollars in 2014 as compared to previous years with average CMP liabilities around $3 million.

The risks of not screening your employees against every state list significantly outweighs the costs of screening, especially when Exclusion Screening, LLCSM is able to efficiently and effectively screen your employees and vendors against all 38 lists at a very reasonable cost to providers.  Call 1-800-294-0952 today to discuss your exclusion screening needs and for a free assessment.

Alert to Florida Providers Regarding Screening

 I.  Florida’s State Exclusion. Excluded Providers Costs OIG Over 2.7 Million

The Office of the Inspector General (OIG) recently released a study on a subset of Florida’s Medicaid payments for pharmaceutical items. The study showed that in 2009 and 2010 the State agency made $180,000 in payments for pharmaceutical items prescribed by excluded providers. OIG, comparing this number to the total number of pharmacy payments, concluded that the State agency may have paid up to $2.7 million for items that excluded providers had prescribed.[1]

OIG concluded that these over-payments occurred because the State agency did not have proper policies in place to conduct prepayment review. Specifically, the agency had not established sufficient prepayment controls to ensure that valid provider IDs were on every pharmacy claim, and that the prescribing provider identification numbers were valid before making payments.

II.  Monthly Exclusion Screening Is Essential to Maintaining Effective Compliance Programs

Furthermore, the State agency was only conducting periodic searches of the LEIE and the GSA-SAM, which are maintained by OIG and CMS, respectively. This serves as just another reminder to providers that exclusion searches, in order to be effective, must be conducted monthly and must include searches of the LEIE, the GSA-SAM, and all 37 state Medicaid lists. Failure to search every list creates a hole in your screening process and allows excluded individuals to continue billing to the Federal health care programs.

Florida has since created its own suspended provider list like a majority of the states. In addition to building this new system, it also refunded the Federal health care programs in the amount of $99,568. That expense could have been avoided with thorough monthly exclusion checks.

III. Conclusion

All providers must conduct monthly exclusion screening on the LEIE, GSA-SAM, and all 37 state Medicaid lists. OIG is aggressively cracking down on providers who employ excluded individuals and will impose Civil Monetary Penalties (CMPs) of up to $10,000 for each item or service billed to the Federal health care programs that was provided directly or indirectly by an excluded individual.

Read more on State Exclusion 

Florida's State Exclusion 

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. Feel free to contact us at 1-800-294-0952 or online for a free consultation.


[1] Lori S. Pilcher, Florida Made Some Payments for Pharmacy Items That Excluded Providers Had Prescribed, Dep’t of Health and Human Servs., Office of the Ins. Gen., 3 (June 2014).

Gary Cantrell Testimony: Failures to Report Adverse Licensing Actions Leads to Gaps in the OIG-LEIE

Gary Cantrell Testimony

HHS/OIG Deputy Inspector General Gary Cantrell testified earlier this year that States are failing to report all of the adverse actions taken by their Licensing Boards. He suggested that the “manner and time of the [reported] notices” are unreliable. Cantrell attributed these concerns to the “voluntary” nature of State reporting obligations.[1]

I.  The Impact on Exclusion Enforcement

Gary Cantrell stressed the importance of the Office of the Inspector General’s (OIG) ability to exclude individuals and entities from participating in federal health care programs as a key administrative tool in fighting fraud. He emphasized that “adverse actions…enable us to identify numerous individuals who are subject to exclusion….” If the OIG, however, is not informed about these individuals in the first instance, or is informed in an untimely way, then it may never become aware that they should be considered for inclusion on the List of Excluded Individuals and Entities (LEIE). This creates a significant risk to the Medicare Trust Fund and thwarts the OIG’s ongoing exclusion enforcement initiative.

Mr. Cantrell stated that the issue arises principally due to the manner in which the information is reported. States report the adverse actions to the OIG on a voluntary basis. It can also be reported from individual State boards, general public notices of State board action, and from the working relationships between OIG exclusion analysts and other agencies. In addition to incomplete reporting, the timing and manner of the notices completely depend on each State’s licensing board. Cantrell recommended that Congress explore requiring more reliable and standardized reporting from State licensing boards to advance OIG’s ability to exclude providers.

II.  OIG’s LEIE and State Exclusion Registries May Differ  

A license revocation or suspension is grounds in of itself for a permissive exclusion. In addition, the facts that support such an action are often grounds for mandatory exclusions. Indeed, as a consequence of the board action and the underlying conduct, the individual or entity is almost certainly going to be included on the specific State Exclusion Registry. This can result, however, in an individual being excluded on a State Registry, but not on the OIG-LEIE!

III.  The Takeaway: Providers Shouldn’t Rely Exclusively on the LEIE

The takeaway for providers is twofold: 1) The LEIE and State Exclusion Registries can, and will, differ from time to time, and 2) In light of this, providers simply cannot rely exclusively on the OIG-LEIE as their sole exclusion screening tool. Providers should screen, at a minimum,[2] the federal lists (LEIE and SAM), their state exclusion list, and any unique additional lists that may be required by their State. 

Ashley Hudson

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. Contact the exclusion experts at Exclusion Screening, LLCSM today for a free consultation by calling 1-800-294-0952 or online.


[1] Testimony of Gary Cantrell, Deputy Inspector Gen. for Investigation Office of the Inspector General U.S Dep’t of Health and Human Servs.; “Medicare Program Integrity: Screening Out Errors, Fraud, Abuse” before the House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, 9 (June 25, 2014).

[2] The exclusion experts at Exclusion Screening, LLCSM automatically screen all State Exclusion lists and strongly recommend that this is a “best practice” for all providers. Our other blog posts on this site more fully discuss our reasons for this recommendation. 

Exclusion Databases: How Difficult Is Screening and Verifying?

exclusion database
I.  Which Exclusion Databases Do I Need to Screen?

The Office of Inspector General (OIG) recommends that you screen your employees, contractors, and vendors every month against the List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM). Your State Medicaid director mandates monthly screening of your State exclusion database, in addition to the LEIE and, perhaps, the SAM.  In a number of states, when you enroll or re-enroll you have to certify that none of your employees or contractors are excluded from any Federal or State Healthcare Program. 

If your State happens to be Texas, you will have to certify that you have conducted an “internal review” to determine if any of your employees or contractors have been excluded from Medicareany State Healthcare program, or from the CHIP program.[1] Unfortunately, each of the 37 databases to be searched (the LEIE, SAM and 37 States) are “stand alone” databases that are unique in their composition, content and the way they can be screened.  This article discusses those differences and the problems associated with them.

II.  Screening the LEIE

The LEIE contains approximately 60,000 persons and is updated monthly. It contains identifying information such as the excluded individual’s name, date of birth, provider type, and other information. It is also searchable or downloadable. The LEIE allows a provider to perform a basic name search. It then provides a list of names that match your search. To determine if the potential match is your employee, the database verifies quickly by Social Security Number (SSN). The OIG describes the process in its May, 2013 Advisory Bulletin as a relatively simple one in which providers only have to “review each job category or contractual relationship to determine whether the item or service being provided is directly or indirectly, in whole or in part, payable by a Federal health care program.” If only it was as easy as the OIG makes it sound.

Although the LEIE is “searchable,” it only allows five names to be searched at a time. In addition, potential matches can only be verified individually by entering the social security number. While this is not a problem for a 10-person practice, the difficulty of checking and verifying increases exponentially with a practice of 100, 1000, or even a provider with 5000 employees, such as a hospital.

The alternative of downloading the LEIE database is equally problematic. Most providers simply do not have the capability to download the LEIE (which contains almost 60,000 names), and compare it with their own employee database in any reliable or economically viable way.

We also note that the LEIE’s matching criteria is not exact and often overlooks potential exclusions. For example, there is no mechanism built into the LEIE that will allow a search for “William Smith” to return matches for common alternatives such as “Bill,” “Will,” “Willie” or “Billy” Smith. Finally, one last significant issue is that the guidance by OIG ignores State screening requirements and regulations. 

III.  GSA-SAM

The System for Award Management (SAM) consolidated the Central Contractor Registry (CCR), Federal Agency Registration (FedReg), Online Representations and Certifications Application (ORCA), and Excluded Parties List System (EPLS) into a single database for federal contractors who were debarred, sanctioned, or excluded for contract or other fraud. The consolidation eliminated certain codes, reclassified others, and uses four exclusion classifications: Firm, Individual, Vessel, and Special Entity Designation (a catch-all phrase for an organization that is not considered a firm, individual, or vessel, but nonetheless needs to be excluded). 

The SAM consists of almost 126,000 excluded entities and providers. It verifies by EIN, CAGE Code, DUNS, NAICS, or PSC. Excluded individuals are verified by SSN. Similar to the LEIE, the SAM is either searchable or downloadable, but it also presents similar problems. For instance, the name search is limited and must be an exact match, so any slight variation will not return a match.

When verifying an excluded provider on SAM by SSN, you are directed to type your employee’s name and his or her SSN into the boxes provided. The database will then report whether the SSN and the provider’s name are a match in SAM. Unlike the LEIE, SAM matches the exact provider name[2] and SSN to the SAM database names and their associated SSNs. This is a big contrast to the LEIE, since SAM does not pull up a list of every person who matched your query for you to verify individually. As with the LEIE, downloading the entire list of 126,000 names and matching it with a large employee list is beyond the capabilities of most providers.

IV.  The States

Even though the States have much smaller exclusion registries, they are even more challenging than both the LEIE and the SAM when it comes to screening and verifying.[3]  Each listing is unique and comes in different document formats, with different fields, and contains different information. As a result of these differences, cross-checking names between State and Federal databases is a significant obstacle to overcome.

When it comes to verification, unlike digital verification as with the LEIE or SAM, most states verify excluded providers by email with the provider’s last four digits of his or her SSN.[4]  Usually, the email for the State’s contact is listed on the State’s exclusion database website or on the list itself. However, it is not unusual for there to be difficulty in tracking down the responsible person, different persons depending on the nature of the exclusion, or nobody listed at all. In those instances, phone skills and perseverance are required to find the right person to talk to. It can also take from around twenty minutes to several weeks to receive a response as to whether the names and SSNs listed are a match.

V.  Screening and Verifying All State Databases

We address why all State and Federal databases should be screened in other blog postings, but it is imperative to note that providers should screen and verify every State database. 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.[5] Accordingly, providers should know how to perform exclusion checks of all State databases. 

VI. Conclusion

While Exclusion Screening, LLCSM has compiled all thirty-seven State and Federal databases into our own searchable database for checks and verifications, this step is beyond the IT ability of most providers due to the variety of list formats (PDF, Word, Excel); the differences in information provided within each database (i.e., some States provide first and last names, while other states provide first, last, and middle names; additionally, some States parse the names into different excel fields, while others leave the entire name in one field); and the constant (usually monthly) updates to each State exclusion list. 

You can see why the checking and verification process is not as simple as OIG and the States may have suggested. Even though the process is time consuming, it is critical that providers check employees, vendors and contractors against all 40 lists. Failure to properly screen employees and vendors could result in CMP liability of up to $10,000 for each item or service furnished directly or indirectly by an excluded individual. Instead of overburdening your current employees, contact Exclusion Screening, LLCSM today and we will do the heavy lifting for you.

Erin Archer

Erin Archer is the author of this article. Feel free to contact us at 1-800-294-0952 or online for a free consultation.


[1] See, e.g., Texas Admin. Code, Rule § 352.5.  An even more exacting obligation is found in Louisiana where provider agreements require applicants to certify that no employees or contractors are currently, nor have ever been, excluded from Medicare, Medicaid or other Health Care Program in any state!

[2] Unlike the LEIE and some State databases, SAM has only one designated field for the provider’s “name,” instead of parsed “first,” “last,” and “middle” name field options.

[3] As of this posting, there are thirty-seven separate state listings.

[4] California and Florida do not verify by SSN.

[5] 42 U.S.C. 1396(a) (2012). Whether an exclusion by one state actually “excludes” an individual from all states or makes him “excludable” from all states is an open question at present, but why take the chance of hiring a person who has been excluded in another State if you don’t have to?