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The ABC’s of OIG Exclusion List Monitoring
The ABC’s of OIG Exclusion List Monitoring

* Updated from original post on 12/17/2015 Healthcare compliance is complicated and full of regulations, guidelines, and oversight. Since federal tax dollars are used to reimburse health care providers for services, the Department of Health and Human Services (HHS) as well as the Department of Justice (DOJ) have oversight on how those dollars are spent. The purpose of this blog post is to give a basic understanding of exclusions, industry best practices, and a brief description of the federal exclusion databases.

States with the Most Excluded Parties
States with the Most Excluded Parties

Which states have the most exclusions? Glad you asked! First off, did you know that there are 40 states that have a state Medicaid exclusion list in addition to the two federal exclusion datasources (OIG-LEIE and SAM.gov)? Did you also know that a state Attorney General’s Office and/or Medicaid Agency can impose an exclusion on a person or entity in addition to the OIG? In today’s compliance environment, it’s important to have a comprehensive monitoring program that is placing just as much emphasis at the state level to achieve 100% compliance.

The Complexities of Exclusion Monitoring
The Complexities of Exclusion Monitoring

Let’s take a stroll down memory lane. Do you remember when you were the new compliance officer in your organization? Maybe you were reviewing all of the compliance processes and trying to determine what was working well and where things might need a little improvement? At some point, if you’re like me, you began to review the exclusion monitoring process and quickly realized you need some help.

The Path of an OIG Exclusion
The Path of an OIG Exclusion

Maybe the Wizard of Oz had good advice: follow the yellow brick road. It may have curves and present different paths, and you may meet some interesting people along the way, but in the end, it can take you to the big castle. In this case, the castle is the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) - the ultimate enforcer for healthcare fraud. The OIG has enforcement powers with the wave of its wand. Those powers include the statutory authority to impose civil fines and penalties (CMP) and exclusions against individuals and/or entities that stray from the yellow brick road.

Quick Guide to Exclusion Searches : LEIE
Quick Guide to Exclusion Searches : LEIE

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.

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