Keep reading to discover 7 not-so-obvious things you should know about OIG exclusions:
1.  An individual can be excluded for defaulting on federal student loans.

In more technical terms, this is referred to as a HEAL (Health Education Assistance Loan) exclusion. Although steps are taken prior to excluding the individual to ensure repayment, failure to resolve the indebtedness declares the individual as in default.

2. To be removed from the OIG exclusion list, an individual must apply for reinstatement.

While this seems somewhat obvious, you’d be surprised how enigmatic this concept really is to most people. Note that reaching the “end date” of your exclusion term does NOT remove you from the OIG exclusion list. Even if your exclusion term expired 5 years ago, you will still be considered excluded until you apply for reinstatement.

3. Applying for reinstatement through the OIG will not reinstate you through other excluding bodies. 

Remember there are other exclusion sources outside of the two federal exclusion datasets, and There are also 40 states that have publicly available Medicaid issues exclusions. If excluded by the OIG and/or another excluding body, you must apply for reinstatement with each to no longer be considered excluded.

4. Sanctions pertaining to license revocation or suspension can be a precursor to exclusion.

A common trend leading to exclusions is the issuance of a disciplinary sanction on the individual involving the revocation or suspension of their health care license. This is an indicator that the individual could be on their way to becoming federally excluded, so proceed with caution.

5. States Take their Sweet Time Reporting to the OIG.

If a state takes action to exclude an individual or entity from participating in federal health care dollar reimbursement, it is safe to assume the states would quickly, and efficiently, report to the central federal OIG List of Excluded Individuals and Entities (LEIE) database. However, surprisingly, states seem to take their time when it comes to sharing their exclusion data.

The OIG advises that all health care companies that employ or conduct business with a third party vendor activate monthly searches of the List of OIG exclusions. If an individual or entity is excluded at the state level, the record is supposed to be shared with the OIG-LEIE so that it is not missed by an employer. But that is not always the case.  

6. System Award Management (SAM) is the EPLS go-to.

The General Services Administration (GSA) administers all procurement databases, including SAM now houses the old EPLS. So SAM is the GSA go-to!  The GSA-EPLS site has not been updated nor is the current repository for SAM debarments and exclusions. So, if just searching GSA-EPLS is what your organization is doing now, you are not getting current data.  In addition, it is now very hard to determine the best steps to take to find out a GSA-EPLS record if it is not current as the database does not offer current lists of agencies to contact. Therefore, make the your go-to for current GSA exclusions and debarments.

7. New rules broaden the authority of the OIG to exclude individuals or entities convicted of an offense in relation to the obstruction of an audit.

As the OIG continues to broaden and enforce its exclusion authority, it is vital to remain informed, and up-to-date, on the ever-changing rules and regulations to ensure compliance.

The OIG has new and expanded exclusion authorities, and as we will outline below, the fines have increased, in some cases double since last year. The Final Rule effective date is February 13, 2017.

On December 6, 2016, the U.S. Dept. of Health and Human Services, Office of Inspector General (OIG) issued rules that incorporate new civil and monetary fines and penalties (CMP) authorities, clarify existing authorities, and reorganize regulations regarding CMP’s. The Final Rule also implements provisions of the Affordable Care Act (ACA) of 2010 that authorizes CMP’s for:

  1. Failure to grant the OIG timely access to records
  2. Ordering or prescribing while excluded
  3. Making false statements, omissions, or misrepresentations in an enrollment application
  4. Failure to report and return overpayments, and
  5. Making or using a false record or statement that is material to a false or fraudulent claim

Michael Rosen, ESQ