OIG Exclusion List
Health care professionals and businesses have to deal with a complicated set of federal and state laws and regulations as well as profoundly negative consequences due to failure to comply with these laws. One of these consequences is the List of Excluded Individuals and Entities (LEIE), where individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs can be found.
The Office of the Inspector General (OIG) may exclude an individual from participation in federal and state health care programs for a variety of offenses:
- Mandatory exclusions result from conviction of healthcare program-related crimes, conviction relating to patient abuse, felony conviction relating to health care fraud or felony conviction relating to controlled substance, and
- Permissive exclusions result from misdemeanor convictions related to health care fraud, misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances, and submission of false or fraudulent claims to a Federal health care program among others.
How Does an Individual or Entity Become Excluded
An OIG exclusion is a final administrative action by the OIG that prohibits participation in any Federal health care program. When an individual or entity is determined to pose risks to patient safety or program fraud, exclusions are imposed, and Federal health care programs will not pay for any service performed by an excluded individual or entity.
Once an individual or entity is excluded, they are considered excluded in all states. In other words, under the Affordable Care Act, an individual or entity excluded in one state is not permitted to participate in federal healthcare funds in all other states.
The OIG’s exclusion process is conducted according to sections of the Social Security Act. The administrative process is the same for both mandatory and permissive exclusions. The OIG sends out a written Notice of Intent to Exclude which includes the reasons for exclusion and its consequences. However, the notification does not necessarily mean that an individual or entity will be excluded. The OIG makes a final decision only after careful consideration of all material provided.Use this detailed guide on exclusion screening to find necessary information on how to achieve healthcare compliance and stay away from the OIG exclusion list.
An exclusion action by the OIG can have significant repercussions on the career and employment of a licensed health professional. However, exclusions are temporary and OIG reinstatement is possible.
Excluded individuals and entities must apply to the OIG for reinstatement and those applications may be submitted 90 days before the expiration of the exclusion period.
OIG Reinstatement Steps:
- Sending a written request to the OIG using this address:
HHS, OIG, OI
P.O. Box 23871
Washington, DC 20026
- Completing the Statement and Authorization forms provided by the OIG;
- Having the Statement and Authorization forms notarized;
- Returning Statement and Authorization forms to the same address mentioned before;
- Waiting for OIG’s decision. This process may last up to 120 days. If the OIG decides to deny the request for reinstatement, excluded individuals or entities may reapply after a year.
Reinstatement of excluded entities and individuals is NOT an automatic process once the specified period of an exclusion ends. At the end of OIG exclusion term, excluded individuals or entities have to apply for reinstatement and receive an authorized notice from OIG that the request was granted. Only then excluded individuals or entities will be able to participate in all federal healthcare programs. Also, if providers are excluded separately at a State exclusion authority, they have to apply separately for reinstatement there. The OIG reinstatement is not the same as reinstatement by or at a State Medicaid exclusion authority.Screen against LEIE, SAM.gov and state exclusion lists with the help of exclusion screening solution and prevent huge delays and potential fines.
OIG Exclusion Effects
The main effect of OIG exclusions is that payment is prohibited for items or services conducted by an excluded individual or entity. This prohibition refers to anyone who employs or contracts with an excluded individual or entity. Providers who violate this prohibition are required to pay back all federal health care program funds that are inappropriately received. According to the OIG special advisory bulletin providers and contracting entities have an affirmative duty to check the program exclusion status of individuals and entities prior to entering into employment or contractual relationships, or run the risk of civil money penalty (CMP) liability if they fail to do so.
Health care providers receiving funds from federal health care programs need to monitor their staff and vendors for exclusions each month to ensure liability is prevented. Without any doubt, it is critical for entities and individuals to run a check on the LEIE to prevent any potential consequences, but also to include SAM.gov and the available state Medicaid Exclusion lists.
While the process of reinstatement can be long and arduous, it is important to take into consideration that excluded individuals and entities are solely responsible for seeking reinstatement as well as that reinstatement is not automatic upon the end of exclusion. In order to have an exclusion that is eligible for reinstatement to be filed, considered, and granted, it is necessary to follow the established procedures in order and at the right point in time. As a result, excluded individuals and entities can effectively get their name off of the OIG exclusion list.Find out how to use technology to maintain compliance, eliminate risks, and reduce costs and resources necessary for effective exclusion screening.