Exclusion is a word we hear often in our line of work, but it can become pretty convoluted with multiple interpretations, definitions, and technicalities that could make your head spin. Many times, compliance professionals don’t recognize where to search, what to look for, or how often they should be monitoring for exclusions. For starters, let’s take a look at how to perform a quick exclusion search via the OIG LEIE. It is the most reliable source for searching for possible excluded individuals or entities. Since Kindergarten, we learned that including people is the right thing to do and that excluding people is akin to saying: “You can’t play with us”. However, there are certain instances where excluding someone or an entity that has been either convicted of or pled guilty to fraud and/or related matters does mean something different.
How to Search for ExclusionsAccording to the OIG site: When the OIG is considering excluding an individual or entity under Section 1128 of the Social Security Act (Act), the administrative process is governed by regulations codified at 42 C.F.R. sections 1001.2001 through 1001.2007. The process varies somewhat, depending upon the basis for the proposed exclusion. For all proposed mandatory exclusions (§§1128(a)(1)-(4) of the Act) that are longer than the mandatory minimum five-year period, and most proposed permissive exclusions (§§1128(b)(1)-(b)(5), (b)(8)-(b)(11), and (b)(14)-(b)(15), and (b)(16) of the Act), the administrative process is the same. The OIG sends out a written Notice of Intent to Exclude to any individual they are considering excluding. The Notice of Intent to Exclude includes the basis for the proposed exclusion and a statement about the potential effect of an exclusion. Here is an example of an OIG exclusion: After entering the name if you have a match, you will need to click on the name or the word “Verify” to continue to verify that you have an exact match. After clicking, the page will refresh with additional information regarding the exclusion. At that point you will need the person’s Social Security Number (SSN), and for an entity, their Employer Identification Number (EIN). If the SSN matches the name on the OIG LEIE page, then the page will refresh with the word “Match” added to the bottom. If the SSN does not match the name on the OIG LEIE site, then the screen will show you “No Match”.
Anatomy of an Exclusion RecordFrom the screenshot above, we can see the Date of Birth (DOB) and specialty (General Medical Practice-MD) along with the address. Most importantly, (if this were a matched provider with the SSN) it would be the Exclusion Type: Section 1128(b)(14) – Default on Health Education Loan or Scholarship Obligation. From the FAQ above, we know that this means it was a discretionary or permissive exclusion. Finally, we have the Exclusion date of 04/20/2003. It would be important to look up the 1128(b)(14) statute and pull the confirmed exclusion record to see the length or term of the exclusion (likely in this case it would have been 5 years or less).
Exclusion Statistics: Did You Know?
- OIG LEIE now has as of (April) 67,084 excluded individuals and entities. Remember, these include state Medicaid exclusion lists too.
- There are a total of 206,186 people and companies excluded by state and federal Exclusion authorities.
- New York
- New Jersey
- New York
- New Jersey