Did you know that multiple provider exclusion lists need to be cross-referenced in order for healthcare organizations to remain compliant with federal programs such as Medicare, Medicaid, CHIP, and more? It can be overwhelming at times to recognize which sources need to be checked for exclusions, and understand how to reference each list. When it comes to federal exclusion lists, the two sources that need to be screened are the HHS OIG List of Excluded Individuals and Entities (LEIE) and SAM.gov, which now includes the GSA Excluded Parties List System (EPLS).
In addition to federal exclusion data, providers, vendors, and third parties need to be screened against all state Medicaid exclusion, sanctioned, or terminated providers lists. For the purposes of this article, let’s take a look at some of the main differences between the HHS OIG LEIE and SAM.gov / GSA exclusion list.
HHS OIG Enforcement for Healthcare Fraud, Waste, and Abuse
The HHS Office of Inspector General (OIG) enforces consequences for non-compliant healthcare organizations, providers, vendors, third party owners, and more.
The OIG mandates that healthcare organizations do not hire or do business with “excluded or sanctioned” individuals or entities. If an individual or entity is excluded, he/she/it is prohibited from participating in reimbursements for or from federally funded healthcare programs“.– Centers for Medicare and Medicaid Services (CMS)
Below are a few examples of how OIG is working to eliminate fraud, waste, and abuse from federal and state healthcare programs.
- Civil fines and monetary penalties
- Corporate Integrity Agreements
- Recommendations for revocating CMS billing privileges
In the last six years, HHS OIG has issued civil fines and monetary penalties in excess of $27 million to more than 250 healthcare organizations for hiring or claiming federal healthcare dollar reimbursements on behalf of excluded persons or entities.
HHS OIG List of Excluded Individuals and Entities (LEIE)
The HHS OIG LEIE consists of individuals and entities who have been excluded from participating in federal healthcare programs. Federal reimbursement, whether direct or indirect, for goods provided or services rendered by an excluded individual or entity, is prohibited. This includes reimbursement for salaries, benefits or items claimed/billed by licensed healthcare providers or administrative personnel. Also, a healthcare organization cannot purchase goods or services from an entity or vendor that is excluded.
Today, the OIG List of Excluded Individuals/Entities has over 60,000 currently excluded individuals and entities. Further, according to Performance Standard 8, all state Medicaid Fraud Control Units (MFCUs), are required to report any actions taken involving terminations and/or exclusions within thirty (30) days of its action to the OIG.
General Services Administration (GSA) and the EPLS
The GSA administers all procurement databases through the System for Award Management (SAM.gov). At one point in time, the GSA administered the Excluded Parties List System (EPLS), which is now included within the System for Award Management SAM.
What is the System for Award Management (SAM)?
According to the SAM.gov website, the database “combines federal procurement systems and the Catalog of Federal Domestic Assistance into one new system…” The System for Award Management’s purpose is to prevent companies from doing business with an individual or entity that has been debarred, sanctioned, or excluded by a federal agency.
The first phase of SAM.gov includes combining the following systems:
- Central Contractor Registry (CCR)
- Federal Agency Registration (Fedreg)
- Online Representations and Certifications Application (ORCA)
- Excluded Persons List System (EPLS)
What to Do if a Record is Found on the SAM.gov Exclusion List?
If a possible record is found on SAM.gov, you are instructed to go to the government agency directly to verify. You will need to know the Dun & Bradstreet number if the excluded party is an entity. If the exclusion is for an individual, there are about four additional steps that must be taken to verify with identifiers, such as SSN. The System for Award Management does not have license information or NPI records like the OIG LEIE does.
SAM.gov does not have the authority to fine an organization like the HHS OIG does. Instead, SAM.gov is a procurement repository. If an organization is debarred, it might not mean that you cannot do business with them. If your organization does not require your vendor to be GSA approved nor is it being reimbursed through federal program dollars, the debarment may not affect your contract (this must be reviewed by your legal counsel).
HHS OIG Exclusion Authorities
OIG has the authority to exclude individuals and entities from Federally funded health care programs pursuant to section 1128 of the Social Security Act (Act) (and from Medicare and State health care programs under section 1156 of the Act) and maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP).
There are two main types of exclusions – mandatory and permissive.
A mandatory exclusion is for a minimum of 5 years and has been imposed for up to 50 years, in certain cases (it can be indefinite if the facts warrant). Once the exclusion period ends, the individual or entity MUST apply for reinstatement at the federal and state level. It is not automatic.
A permissive exclusion can be up to 5 years (typically 1-3 years). At the conclusion of the exclusion period, the individual or entity MUST apply for reinstatement at the federal and state level. It is not automatic.
Smarter Exclusion Monitoring for Healthcare
Healthcare organizations must have a comprehensive approach to screening their providers against various excluded lists.
It is best practice search the OIG LEIE and SAM.gov websites in addition to all available state Medicaid lists. This practice will ensure that you are not employing or contracting with an excluded person or entity.
We’ve made it easy to reference healthcare exclusion data all from one convenient location. Check out our interactive exclusions map to see how many exclusions are present from the OIG LEIE, SAM.gov, and all state Medicaid excluded / sanctioned / or terminated provider lists.
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Written by Michael Rosen, Esq.
Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.