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 below. 



 

 

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?

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.

State exclusion list

In addition to the federal lists, forty-one states now have their own state exclusion list.  These states require, at a minimum, that providers check their employees and contractors against their state exclusion 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 exclusion list, but every available state exclusion list. The reason we recommend screening your employees against every available federal and state exclusion 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 41 lists at a very reasonable cost to providers. 

Call 1-800-294-0952 or fill out the form below today to discuss your exclusion screening needs and for a free assessment.

 

 



Who Should Be on my OIG Exclusion Screening List?

oig exclusion screening list
I. Federal and State Agencies Conducting Audits

As many health care providers and suppliers have painfully learned over the last year, federal and state law enforcement agencies, along with many of the contractors with whom they work, are actively conducting audits of Medicare and Medicaid claims submitted to the government for coverage and payment.

One of the least understood mandatory obligations applicable to virtually every health care provider and supplier who accepts Medicare or Medicaid is the requirement that all participating providers are REQUIRED to screen more than just their staff. Instead, they must also screen contractors, vendors, and agents to ensure that they and their employees have not been excluded from participation in federal and state health care programs. The fact that these individuals and entities must be screened through literally dozens of federal and state exclusion databases further complicates this mandate. 

II. Broad Scope of OIG Exclusion Action

Importantly, the scope of an exclusion action is extremely broad. The Department of Health and Human Services, Office of Inspector General (HHS-OIG) has taken the position that if a vendor, contractor or supplier of administrative, management or support services has been excluded from participating in the Medicare or Medicaid programs, they are effectively barred from working with most health care provider and supplier entities. As HHS-OIG writes:

Excluded persons are prohibited from furnishing administrative and management services that are payable by the Federal health care programs. This prohibition applies even if the administrative and management services are not separately billable. For example, an excluded individual may not serve in an executive or leadership role (e.g., chief executive officer, chief financial officer, general counsel, director of health information management, director of human resources, physician practice office manager, etc.) at a provider that furnishes items or services payable by Federal health care programs. Also, an excluded individual may not provide other types of administrative and management services, such as health information technology services and support, strategic planning, billing and accounting, staff training, and human resources, unless wholly unrelated to Federal health care programs.”1

At Exclusion ScreeningSM, we realize that compiling a list of all employees, vendors and contractors can be a daunting task. That’s why we help our customers evaluate and determine exactly who needs to be included during their monthly Exclusion Screening. 

III.  Creating Your OIG Exclusion Screening List

A partial listing of the parties you are required by law to screen include:

All employees and Staff: To properly screen you should be sure to examine (or submit this information to us so we can conduct the screens for you):

1.  SSN.

2.  Maiden names.

3.  Any former names.

4.  Birthdate.

Vendors, Contractors and Agents: You MUST screen vendors that provide items or services directly OR indirectly that are payable in whole or in part by the Federal health care programs2

Some potential vendors that must be included on your list:

1.  Ambulance and other Transportation Service Providers.

2.  Volunteers.

3.  IT Solution Providers.

4.  Security Technicians.

5.  Medical Equipment Managers.

6.  Food Service Workers.

7.  Lab Technicians.

8.  Pharmacists.

9.  Nurses and other Individuals Provided by Staffing Agencies.

10. Physician Groups that Provide Emergency Room Coverage.

11. Billing or Coding Contractors.

12. Directors.

13. Administrators.

14. Managers.

IV.  Contractors and Vendors

When it comes to contractors and vendors, HHS-OIG offers some interesting guidance in its 2013 Special Advisory. The OIG gives providers two options: (1) providers themselves may screen their contractors’ or vendors’ employees;3 or (2) a provider may rely on a contractor’s or vendor’s certification that the contractor or vendor is conducting screening of its own employees and contractors. Note that HHS-OIG recommends that the provider validate that the contractor is conducting such screening on behalf of the provider. One way providers can validate this information is by requesting and maintaining screening documentation from the contractor.4

V.  Screen for Exclusions: Avoid CMPs!

Screening this list can seem like a daunting task, but not doing so can create a world of hurt. The phrase “leave no stone unturned” couldn’t be more appropriate in this case. An effective compliance policy demands that providers employ comprehensive screening practices. Although the process may seem arduous, the risks providers face, if they do not screen, are dire. The Civil Monetary Penalty (CMP) for any item or service provided by an excluded individual or entity is up to $10,000. On top of CMPs, the providers may be required to pay up to three times the total amount of claims submitted to Medicare.  

Considering the hefty liabilities tacked on for merely employing even one excluded individual, it’s easy to see that making the effort to properly screen for exclusions pays for itself. If you’re worried that your organization isn’t screening the right individuals and entities, the exclusion experts at Exclusion ScreeningSM are happy to help you create your employee and vendor list. Feel free to contact us at 1-800-294-0952 or fill out the form below.

 



 

Ashley Hudson, oig exclusion screening list

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]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15

[2]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15

[3]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15-16

[4]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 16