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 indiviudals 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 Exclusions

According 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:

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 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”.

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Anatomy of an Exclusion Record

From 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 lenghth 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.  

Top 5 States with People Excluded:

  1. California
  2. Texas                           
  3. New York                     
  4. Pennsylvania               
  5. New Jersey                

Top 5 States with Companies Excluded:

  1. New York                    
  2. California                      
  3. Texas                             
  4. Florida                              
  5. New Jersey   

Summary:

Checking for exclusions should be done monthly and conducted on all employees, third party contractors/vendors if your health care organization is receiving federal health care dollars (Medicare, Medicaid, CHIPS, TriCare). A complete exclusion monitoring program includes searching the OIG LEIE and SAM, as well as the available state Medicaid Exclusion lists.   

Make sure that for each search you have the minimum necessary information; names and SSN. Also, a National Practitioner Identification Number (NPI), address, discipline, and DOB are very helpful.  

If you need help enhancing your monthly exclusion monitoring program please feel free to reach out to us. We are compliance experts in this area and can help you automate and simplify the process.


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Written by Michael Rosen, ESQ

ProviderTrust Co-Founder, mrosen@providertrust.com

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.

 Connect with Michael on Linkedin 

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