# Exclusion Screening > Exclusion Screening provides specialized services designed to help organizations ensure compliance and mitigate risks by conducting monthly exclusion screening. With a focus on delivering peace of mind, Exclusion Screening takes care of the end-to-end screening process for customers. Exclusion Screening is efficient utilizing a cutting edge technology plus industry expertise to implement cost effective screening solutions. > Exclusion Screening is tailored for businesses seeking to perform exclusion checks in across medicare, medicaid, ensuring that they make informed decisions about their vendors, employees and partners. The service emphasizes accuracy and completeness, making it a reliable choice for businesses aiming to maintain a safe and compliant environment. --- ## General Info - [AMBA](https://exclusionscreening.com/amba/): WElcome AMBA Members Exclusion Screening has been supporting AMBA members in carrying forward the continuity of the medical billing and... - [First Light](https://exclusionscreening.com/first-light/): HOME CARE Welcome, FirstLight Home Care team We’re here to bring you peace of mind by making exclusion screening simple,... - [Contractor & Vendor Screening](https://exclusionscreening.com/contractor-vendor-screening/): Understanding Obligations, Risks, and Best Practices Contractor & Vendor Screening While many organizations are aware that they have to screen... - [Exclusion Screening](https://exclusionscreening.com/exclusion-screening/): Compliance with precise exclusion screening. Exclusion Screening For Employees We offer an exclusion screening service against over 42 separate Exclusion... - [Compliance Hotline](https://exclusionscreening.com/compliance-hotline/): Compliance Hotline Reduce risk with empowered reporting Created by healthcare industry experts, our Compliance Hotline helps you cultivate an ethically... - [What We Do](https://exclusionscreening.com/what-we-do/): Comprehensive Exclusion Screening Solutions. We approach exclusion screening through a provider-focused method. Mitigate risks and ensure compliance with our commitment... - [Terms of use](https://exclusionscreening.com/terms-of-use/): Standard Terms of Use Terms of Use Updated on September 3, 2025 These Terms of Use are incorporated by reference... - [Schedule a Demo](https://exclusionscreening.com/schedule-a-demo/): Schedule a Free Consultation We monitor all Federal & State Exclusion Lists Made for providers in mind. Start protecting your... - [Contact](https://exclusionscreening.com/contact/): Contact Us We monitor all Federal & State Exclusion Lists Made for providers in mind. Start protecting your business today... - [About](https://exclusionscreening.com/about/): We Understand Your Business, Your Needs, and Understand Law. Exclusion Screening, LLC is the only screening company developed by nationally... - [Home](https://exclusionscreening.com/): Founded by healthcare attorneys with 70 + years of Combined Experience Peace of Mind, Guaranteed. Exclusion Screening by the Experts... - [Blog](https://exclusionscreening.com/resources/) - [Privacy Policy](https://exclusionscreening.com/privacy-policy-2/): Standard Terms of Use Privacy Policy These Terms of Use are incorporated by reference into the Agreement for License of... --- ## Topical deep dives - [Current States With a Separate Medicaid Exclusion List](https://exclusionscreening.com/state-exclusion-databases-medicaid-exclusion/): Map of the States with a Separate Medicaid Exclusion List Click on your state to view their Medicaid exclusion list.... - [A Provider's Guide to Washington State Medicaid](https://exclusionscreening.com/a-providers-guide-to-washington-state-medicaid/): This guide is intended to assist Apple Health providers on exclusion and sanction screening obligations for anyone whose role could... - [Who Can Request An Exclusion Waiver?](https://exclusionscreening.com/who-can-request-an-exclusion-waiver/): Authorized Requester Only the administrator of a Federal or state health care program (e. g. , Medicare or Medicaid director)... - [Compliance Hotlines are Crucial in Healthcare](https://exclusionscreening.com/compliance-hotlines-are-crucial-in-healthcare/): Compliance hotlines are crucial in healthcare because they directly support patient safety, legal protection, and organizational integrity. Healthcare is one... - [Exclusions can be Devastating for Small Practices](https://exclusionscreening.com/exclusions-can-be-devastating-for-small-practices/): Exclusions from participation in federal and state healthcare programs represent a significant and often devastating threat to healthcare providers, especially... - [What Does It Mean To Be On An Exclusion List?](https://exclusionscreening.com/what-does-it-mean-to-be-on-an-exclusion-list/): Being on an exclusion list means that an individual or entity has been barred from participating in a sponsored benefit... - [How Providers Can Check OIG Exclusions on Their Own](https://exclusionscreening.com/how-providers-can-check-oig-exclusions-on-their-own/): This guide helps ensure compliance by verifying that individuals and entities are not excluded from participation in federal healthcare programs... - [Top 5 Challenges in Exclusion Monitoring and How to Solve Them](https://exclusionscreening.com/top-5-challenges-in-exclusion-monitoring-and-how-to-solve-them/): Exclusion monitoring is a mandatory and complex compliance function critical to minimizing liability risks for healthcare providers. The difficulty inherent... - [What to Do If You Have a Confirmed Exclusion](https://exclusionscreening.com/what-to-do-if-you-have-a-confirmed-exclusion/): Finding out that an employee, vendor, contractor, or volunteer has a confirmed exclusion is a serious compliance emergency. Since Federal... - [Why is it Necessary to Screen the NPPES Registry Database?](https://exclusionscreening.com/why-is-it-necessary-to-screen-the-nppes-registry/): We are sometimes asked, “Why do you screen against the National Plan and Provider Enumeration System (NPPES). ” That is... - [Practices Need Hotlines in Their Compliance Program](https://exclusionscreening.com/practices-need-hotlines-in-their-compliance-program-2/): The OIG’s November 2023 Compliance Guidance The OIG’s November 2023 Compliance Guidance lists 7 elements of an effective compliance program.... - [A Provider Guide to New York Medicaid Exclusion Screening](https://exclusionscreening.com/a-provider-guide-to-new-york-medicaid-exclusion-screening/): This article focuses on helping providers understand New York Medicaid exclusion screening law, and its exclusion screening requirements so that... - [A Provider Guide to Alabama Medicaid Exclusion Screening](https://exclusionscreening.com/summary-of-alabama-medicaid-exclusion-and-sanction-screening-requirements/): This short question and answer summary will help providers understand and comply Alabama’s exclusion and sanction screening rules and regulations. - [Comparison between OIG Exclusion List and CMS Preclusion List](https://exclusionscreening.com/oig-exclusion-vs-cms-preclusion-list/): Since the CMS Preclusion list was announced in April 2018, and then published in January 2019, there has been confusion... - [What is an Exclusion Waiver and Who May Apply for one?](https://exclusionscreening.com/oig-exclusion-waiver/): We have previously discussed that once a provider is excluded he may not furnish items or services paid for by the... - [California Exclusion List Screening Requirements](https://exclusionscreening.com/california-exclusion-screening-requirements/): What are the California Exclusion List Screening requirements? The Medi-Cal Program will not pay for any item or service furnished... - [Pennsylvania Medicheck Preclusion List: A Provider’s Guide to Screening](https://exclusionscreening.com/pennsylvania-exclusion-screening/): The Pennsylvania Precluded Provider List, commonly referred to as “Pennsylvania Medicheck ,” identifies individuals and entities who have been excluded... - [How the LEIE, GSA/SAM, and State Exclusion Lists Differ; And Why They Need to be Screened](https://exclusionscreening.com/different-exclusion-lists/): Exclusions and debarments are powerful administrative sanctions imposed by Federal and State agencies. They are intended to protect their programs... - [A Provider’s Guide to the GSA SAM Database.](https://exclusionscreening.com/unlocking-gsa-sam-mystery/): The importance of screening employees, vendors and contractors against available federal and State exclusion databases cannot be overemphasized. Despite the... - [About the Medi-Cal Suspended and Ineligible Provider List](https://exclusionscreening.com/overview-of-the-medi-cal-suspended-and-ineligible-provider-list/): California’s Medi-Cal Suspended and Ineligible Provider List is Designed to Safeguard Beneficiaries and Protect the Financial Integrity of the Medi-Cal... - [A Provider's Guide to OIG Exclusions](https://exclusionscreening.com/providers-guide-to-oig-exclusions/): A Provider’s Guide to OIG Exclusions: Federal Exclusion Regulations and Enforcement Authorities, and How Providers Can Avoid Risk with Proper Exclusion... - [What is an OIG Exclusion?](https://exclusionscreening.com/oig-exclusion-list/): OIG Exclusions are powerful enforcement sanctions that bar an individual or entity from any participation in Federal and State health... - [Why Should We Screen Against the Social Security Administration Death Master File?](https://exclusionscreening.com/screening-the-social-security-death-master-file/): At Exclusion Screening, we often receive questions about the scope and frequency of an organization’s screening duties and responsibilities. One... - [Resolving Exclusion Violations through the OIG Self-Disclosure Protocol](https://exclusionscreening.com/resolving-exclusion-violations-through-the-oig-self-disclosure-protocol/): I. Introduction The Office of Inspector General (OIG) has the authority to exclude providers from participating in federal health care... - [Medicare / Medicaid Providers Beware: A Nolo Contendere Plea to a Non-Health Care Crime Can Still Result in Exclusion from Medicare](https://exclusionscreening.com/medicare-medicaid-providers-beware-nolo-contendere-plea-non-health-care-crime-can-still-result-exclusion-medicare/): The last two years have been rough for everyone, and it has been particularly difficult for health care providers and... - [The Proposed Expansion of CMS’ Revocation Authority Makes Monthly Exclusion Screening of ALL Employees More Important than Ever!](https://exclusionscreening.com/cms-revocation-authority/): The Centers for Medicare and Medicaid Services (CMS) is the Federal agency tasked with the overall responsibility of managing the... - [When an Underlying Misdemeanor or Felony Conviction is Expunged, Does That Extinguish an Exclusion Action?](https://exclusionscreening.com/expunged-conviction-extinguish-exclusion/): Medicare and Medicaid providers / suppliers are prohibited from employing individuals who have been excluded from participation in Federal health... - [North Carolina Exclusion Screening Requirements](https://exclusionscreening.com/north-carolina-exclusion-screening-requirements/): To understand the North Carolina Exclusion Screening Requirements, we must first touch upon Exclusions in general. Office of Inspector General... - [What is the NPDB?](https://exclusionscreening.com/npdb/): I. What is the NPDB The National Practitioner Data Bank (NPDB) was created as part of the Health Care Quality... - [What is the Length of A Mandatory Exclusion?](https://exclusionscreening.com/what-is-the-length-of-a-mandatory-exclusion/): The Department of Health and Human Services (HHS), Office of Inspector General (OIG) is responsible for overseeing the financial and... - [What is the Scope of a Mandatory Exclusion Brought Under Section 1128(a)(4) of the Social Security Act (Act)?](https://exclusionscreening.com/mandatory-exclusion-under-section-1128a4/): The Department of Health and Human Services (HHS), Office of Inspector General (OIG) exercises both mandatory and permissive exclusion authority... - [Exclusion Actions Under 42 U.S.C. § 1320a-7(b)(5)(B) -- The Collateral Consequences of a State Medicaid Enrollment Termination Action](https://exclusionscreening.com/collateral-consequences-state-medicaid-enrollment-termination-action/): Exclusion Actions Under 42 U. S. C. § 1320a-7(b)(5)(B) (November 2020): Since 1976, the Department of Health and Human Services... - [Which Federal & State Exclusion Lists Should Be Screened?](https://exclusionscreening.com/which-exclusion-lists-should-be-screened-2/): The complex web of regulation encompassing government health care dollars is a lot to take on. With 41 state exclusion... - [A State Conviction for “Patient Neglect” Will Result in Mandatory Exclusion from Participation in Federal Health Benefit Programs ](https://exclusionscreening.com/mandatory-exclusion-state-convitions/): The Department of Health and Human Services (HHS), Office of Inspector General (OIG) may be required by law under Section... - [I Have a Confirmed Exclusion What are my Options](https://exclusionscreening.com/confirmed-exclusion-options/): After finding a confirmed exclusion among your employees, vendors, contractors, or volunteers there are several options you can take. Each... - [Massachusetts Medicaid Exclusion Screening Requirements](https://exclusionscreening.com/massachusetts-medicaid-exclusion/): Massachusetts Medicaid Exclusion Screening: Requirements and Best Practices for Compliance The Massachusetts Medicaid Exclusion requirements, under MassHealth, will not reimburse... - [Can a Medicare Provider or Supplier Hire an Excluded Individual or Enter in a Contract with an Excluded Entity on the Medicare Exclusion List?](https://exclusionscreening.com/hiring-federally-excluded-individuals/): Should you choose to participate in the Medicare and/or Medicaid programs, you must comply with a wide variety of program... - [Pennsylvania Doctor Excluded in Connection with Quality of Care](https://exclusionscreening.com/pennsylvania-doctor-excluded/): Over the past year, both State and Federal law enforcement investigators and prosecutors have gone to considerable lengths to publicize... - [OIG Semiannual Report to Congress: Fall 2018-Spring 2019](https://exclusionscreening.com/oig-semi-annual-report-congress-fall-2018-spring-2019/): The Office of Inspector General (OIG) recently published its Semi-Annual Report to Congress covering from October 1, 2018 to March... - [Alabama Exclusion Screening Requirements](https://exclusionscreening.com/alabama-exclusion-screening-requirements/): (May 2, 2019) The Alabama Medicaid Program imposes significant exclusion screening requirements on its providers. Many are unaware of the extent... - [New Evidence Shows the Efficiency and Benefits of Using an Internal Compliance Hotline System](https://exclusionscreening.com/internal-compliance-whistleblowing-system/): (April 4, 2019): In December of 2018 a study was conducted by Kyle Wench (George Washington University) and Stephen Stubben... - [OIG Enforcement Actions: Notable Decisions from March 2019](https://exclusionscreening.com/oig-enforcement-actions-notable-decisions-from-march-2019/): (April 2, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), has continued its goal... - [February Recap of OIG Enforcement Actions: Notable Decisions ](https://exclusionscreening.com/february-recap-oig-enforcement-actions-notable-decisions/): (March 1, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), has continued its goal... - [What to Know About the New CMS Preclusion List](https://exclusionscreening.com/cms-preclusion-list/): Beginning April 1, 2019, the new CMS Preclusion List will go into effect subsequently barring many healthcare professionals from receiving... - [A Review of OIG Enforcement Actions in Fiscal Year 2018](https://exclusionscreening.com/review-oig-in-fiscal-year-2018/): By Cason Liles (February 6, 2019): The Department of Health and Human Services (HHS), Office of Inspector General (OIG) is an... - [OIG Enforcement Actions: Notable Decisions from January 2019](https://exclusionscreening.com/oig-enforcement-actions-notable-decisions-january-2019/): (February 6, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), didn’t skip a beat... - [A Provider’s Guide to Texas Medicaid Exclusions: Exclusion Screening Requirements and Best Practices for Compliance](https://exclusionscreening.com/texas-medicaid-exclusions/): (December 17, 2018): Texas Medicaid Exclusions will prevent the Texas Medicaid Program from paying for any item or service furnished... - [OIG Exclusion Case Study: The Impact of a False Claims Act Judgment.](https://exclusionscreening.com/oig-exclusion-case-study-impact-false-claims-act-judgment/): (August 23, 2018): In 2008, after learning that a Texas-based laboratory services company was submitting false claims to the Medicare... - [Health Care Providers Should Consider the Ramifications of “Taking a Plea” in a Criminal Case or Agreeing to a Licensure Action. It May Trigger a Mandatory or Permissive OIG Exclusion Action.](https://exclusionscreening.com/licensure-action-oig-exclusion/): Perhaps the most severe administrative sanction available under the Social Security Act stems from the authority of the Secretary for... - [Personal Care Service Aides and Attendants Excluded in 2017](https://exclusionscreening.com/personal-care-service-aides-attendants-excluded-2017/): (January 22, 2018): With 2017 behind us, it can be quite helpful to review the Medicare “exclusion” actions taken by the... - [Dental OIG Exclusions - A Review of 2017 Actions.](https://exclusionscreening.com/dental-oig-exclusion-actions/): (January 12, 2018): The Medicare and Medicaid programs are both essential, yet costly health benefit programs sponsored in whole or... - [Reciprocal Licensure Actions Can Lead to Medicare Revocation and Exclusion](https://exclusionscreening.com/medicare-revocation-and-exclusion/): (January 8, 2018): Most physicians will progress through their entire career without ever having to respond to a complaint or... - [The Released Year in Review OIG Podcast](https://exclusionscreening.com/oig-podcast/): Year in Review OIG Podcast Earlier this week, the Office of Inspector General released its “Year in Review” OIG Podcast... - [Pain Management Prescribing Practices and Audits](https://exclusionscreening.com/pain-management-prescribing-practices/): (August 16, 2017): Earlier this summer, the U. S. Department of Justice (DOJ) executed its most extensive “health care fraud... - [Significant Recent Trends in Exclusion Case Settlements](https://exclusionscreening.com/significant-recent-trends-exclusion-case-settlements/): The Office of the Inspector General (OIG) has recently entered into a number of exclusion case settlements tied to skilled nursing facilities... - [Health Care Fraud to Remain a DOJ Priority](https://exclusionscreening.com/home-health-final-rule-exclusion/): Exclusion News (May 22, 2017):Health Care Fraud will continue to be a high priority of the Department of Justice Kenneth... - [The New “Seventh Element” of Compliance: Screening and Evaluating Employee Suitability!](https://exclusionscreening.com/exclusion-screening-compliance-role/): The recently issued Resource Guide for Measuring Compliance Program Effectiveness, reconfigures the traditional formulation of the “Seven Elements of an... - [Home Health Final Rule Extends Exclusion Screening Obligation: Failure to Screen Could Result in Termination from Medicare](https://exclusionscreening.com/home-health-final-rule-exclusion-screening-condition-of-participation/): By Paul Weidenfeld The new Final Rule issued by CMS revising the conditions of participation for home health agencies (HHAs) requires... - [Pharmacies Targeted for Exclusion Violations by OIG and States](https://exclusionscreening.com/pharmacies-targeted-exclusion-violations-oig-states/): In what appears to be a growing enforcement trend, the Department of Health and Human Services, Office of Inspector General... - [Excluded Dentist Pays Record $1.1 Million and Agrees to 50 Year Exclusion](https://exclusionscreening.com/excluded-dentist-pays-1-million-penalty/): Exclusion Violation by Dentist “Sends a Strong Warning” The Office of the Inspector General’s (OIG) announced last week that it... - [OIG Issues Final Rule Expanding Exclusion Authority](https://exclusionscreening.com/oig-expands-exclusion-authority/): On January 12, 2017, the Office of Inspector General published a final rule finalizing revisions to its exclusion authorities. The... - [DOJ Announces $4.7B in FCA Recoveries: What Does It Mean?](https://exclusionscreening.com/doj-announces-fca-recoveries-4-7-billion/): DOJ Announces $4. 7 billion in FCA Recoveries The “Third Best Year” in False Claims Act History? The Department of... - [2016 OIG Work Plan: State Medicaid Agencies Must Comply with Exclusion Rules](https://exclusionscreening.com/2016-oig-work-plan/): The Office of Inspector General’s 2016 OIG Work Plan contains two important projects that focus on the enforcement of exclusion... - [OIG Imposes Record Penalties for Exclusion Violations](https://exclusionscreening.com/exclusion-violations-net-record-penalties/): OIG Imposes Record $21. 5 Million in Penalties for Exclusion Violations! The OIG imposed a record $21. 5 million civil... - [What Medical Practices Need to Know About OIG Exclusion Screening](https://exclusionscreening.com/oig-exclusion-screening/): The Office of Inspector General (OIG) has steadily increased its enforcement of OIG Exclusion Screening violations since the issuance of... - [DOJ Doubles Down on False Claims Act Penalties!](https://exclusionscreening.com/doj-doubles-false-claims-act-penalties/): The False Claims Act is the primary civil enforcement tool utilized by the federal government in its fight against fraud... - [OIG Issues Updated Criteria for Implementing Its Permissive Exclusion Authority](https://exclusionscreening.com/oig-permissive-exclusion-authority/): On April 18, 2016, the Department of Health and Human Services, Office of Inspector General (HHS-OIG) issued updated criteria for... - [How to Apply for OIG Reinstatement](https://exclusionscreening.com/applying-for-reinstatement/): I. The OIG Reinstatement Process Most exclusions are imposed for a definite time period. The question for an excluded individual... - [How Compliance Hotlines Can Save You Money!](https://exclusionscreening.com/compliance-hotlines/): By Paul Weidenfeld, March 4, 2016. An essential element of all compliance plans is developing and promoting “effective lines of... - [Exclusion Loophole: Medicaid Managed Care](https://exclusionscreening.com/exclusion-loophole-medicaid-managed-care/): In August, we discussed an OIG audit, which revealed that Medicaid providers who were terminated for cause were often able... - [Who Is to Blame for Gaps in OIG and State Exclusion Lists? What Is the Impact on Providers?](https://exclusionscreening.com/gaps-in-oig-and-state-exclusion-lists/): The failure to report excludable offenses by state Medicaid offices and licensing boards is a longstanding issue for the OIG.... - [Health Care Fraud: Second Conviction Secured in Michigan Excluded Provider Scheme](https://exclusionscreening.com/excluded-provider-health-care-fraud/): In February, we reported that the Michigan Attorney General secured a racketeering and health care fraud conviction against an excluded... - [Pennsylvania Judge Holds that CIA violations May Result in FCA Liability](https://exclusionscreening.com/oig-corporate-integrity-agreement/): In late July, a federal district court in Pennsylvania joined in the flurry of False Claims Act (FCA) decisions. These... - [2015 Mid-Year Exclusion Enforcement Action Review](https://exclusionscreening.com/2015-mid-year-exclusion-enforcement-action-review/): OIG has been busy cracking down on providers who employ or contract with excluded persons or contractors. In fact, by... - [Excluded Individual Conducts Elaborate Health Care Fraud Scheme](https://exclusionscreening.com/excluded-individual-elaborate-health-care-fraud-scheme/): The owner of a New Jersey ambulance company was indicted for health care fraud in mid-August of 2015. The owner... - [Exclusion Screening Required in United States Territories](https://exclusionscreening.com/exclusion-screening-required-in-united-states-territories/): Our experts at Exclusion Screening, LLC maintain fact sheets that contain the screening requirements for providers in every state, including... - [Why Do I Need a Compliance Hotline?](https://exclusionscreening.com/compliance-hotline/): One of the seven steps to an effective compliance plan is to develop effective lines of communication. While it is... - [Southern District of New York Provides Clarity on “Identifying” Overpayments](https://exclusionscreening.com/false-claims-act-liability-overpayments/): In early August of 2015, the Southern District of New York (SDNY) provided insight as to when the 60-day clock... - [Recent Developments on the 60-day Rule and the Potential Impact on Exclusion Violations](https://exclusionscreening.com/60-day-rule-exclusion-violations/): The Affordable Care Act (ACA) creates a 60‑day window to report and return overpayments from Medicare or Medicaid after the... - [Medicaid Providers That Are Excluded or Terminated for Cause Often Continue to Participate in Other States According to a New OIG Audit](https://exclusionscreening.com/excluded-medicaid-providers/): OIG Audit Findings In a recently released audit, the OIG found that despite the ACA requirement that states terminate Medicaid... - [DOJ Files Another False Claims Act Case Based on OIG Exclusion Violations](https://exclusionscreening.com/false-claims-act-oig-exclusion-violations/): DOJ Pursuing Action on Two Separate OIG Exclusion Violations The U. S. Attorney’s Office in Philadelphia filed a False Claims... - [Exclusion Alert: Assistant Inspector General Tells Congress That Exclusion Violations Plague Part D](https://exclusionscreening.com/ann-maxwell-exclusion-violations-part-d/): Assistant Inspector General Testifies before Congress Ann Maxwell, the Assistant Inspector General for Evaluation and Inspections, recently testified before Congress.... - [OIG Announces Creation of Special Unit for CMP and Exclusion Litigation](https://exclusionscreening.com/special-litigation-unit/): Exclusion Screening, LLC has been chronicling the Office of Inspector General’s (OIG) interest in exclusion enforcement for quite some time.... - [Exclusion Screening of Contractors and Vendors](https://exclusionscreening.com/exclusion-screening-contractors-vendors/): By now, providers should be aware that the Office of Inspector General (OIG) requires exclusion screening of contractors and vendors, in... - [Exclusion Screening Basics for Providers](https://exclusionscreening.com/exclusion-screening-basics/): Exclusion Screening Is Mandatory Providers of medical services that participate in Federal or State Health Care Programs are required to... - [Exclusion Case Review: 1st Quarter of 2015 Evidences an Increase in Enforcement Efforts by OIG](https://exclusionscreening.com/exclusion-case-review-1st-quarter-of-2015-evidences-an-increase-in-enforcement-efforts-by-oig/): (This article was originally posted in the National Alliance of Medical Auditing Specialists‘ “Tip of the Week”) At Exclusion Screening,... - [DOJ Announces New FCA Settlements involving Excluded Persons including a $6.5 Million Settlement involving Services Provided by a Private Duty Nurse Investigated by OIG](https://exclusionscreening.com/oig-fca-settlements-excluded-persons/): The Department of Justice (DOJ) recently announced two new False Claims Act (FCA) settlements involving excluded persons. The first was a... - [HHS/OIG Excludes Illinois Home Health Agency for Exclusion Violation!](https://exclusionscreening.com/hhs-oig-illinois-exclusion/): Home Health Agency Excluded for Employing Excluded Nurse HHS/OIG recently issued a press release announcing that it had excluded an... - [OIG Releases Medicaid Fraud Control Unit (MFCU) Annual Report for FY2014](https://exclusionscreening.com/mfcu-annual-report/): I. Gains in State Exclusion Enforcement Efforts Highlighted The Office of the Inspector General’s (OIG) annual Report for the State Medicaid... - [Medicare and Medicaid Exclusion Screening Compliance: A Challenging Problem with a Surprisingly Simple Solution](https://exclusionscreening.com/medicare-medicaid-exclusion-screening-compliance/): Since August 2014, the Office of Inspector General (OIG) has collected roughly $3. 75 Million in Civil Money Penalties (CMPs) in... - [OIG's Updated Special Advisory Bulletin on the Effect of Exclusions](https://exclusionscreening.com/oig-special-advisory-bulletin/): The Office of the Inspector General (OIG) Broadly Interprets Exclusion Regulations OIG’s Demonstrated Interest in Exclusion Screening and Forewarning of... - [Hospital Enters into False Claims Settlement for Employee with Lapsed License](https://exclusionscreening.com/false-claims-settlement-lapsed-license/): I. Hospital Employed Therapist with Lapsed License The Department of Justice (DOJ) entered into a settlement with a nonprofit Michigan hospital this... - [DC Contractor for Dental Providers Indicted for False Claim](https://exclusionscreening.com/false-claim-contractor-dental-providers/): I. Fraud Found in HHS’ Backyard A Virginia contractor for dental providers was recently indicted by a grand jury on... - [Review of February, 2014 Exclusion Cases: Focus on Nursing Homes Remains High and the Cost of Violations Rise](https://exclusionscreening.com/oig-exclusion-cases-target-nursing-homes/): I. OIG Targets Nursing Homes Last year almost half of the exclusion violation matters reported by the Office of the... - [Excluded Podiatrist Convicted of Racketeering and Health Care Fraud](https://exclusionscreening.com/excluded-podiatrist-racketeering-health-care-fraud/): I. Excluded Podiatrist Commits Health Care Fraud A Michigan podiatrist who was excluded from participation in the Federal health care... - [OIG Issues Advisory Opinion on Exclusions](https://exclusionscreening.com/oig-issues-advisory-opinion-exclusions/): I. Advisory Opinion on Payments for Services Provided Prior to Exclusion The Department of Health and Human Services Office of... - [2014 In Review – OIG Crack Down on Exclusion Violations](https://exclusionscreening.com/2014-review-oig-enforcement-actions/): I. CMPs doubled in OIG Exclusion Violations 2014 Exclusion Screening, LLCSM dedicates a significant amount of time to examining the... - [OIG Trumpets Exclusions, New Actions and Recoveries in its Semi-Annual Report to Congress](https://exclusionscreening.com/oig-report/): I. OIG Report In the Office of the Inspector General’s (OIG) semiannual report to Congress, it claimed credit for excluding 2,297 individuals... - [Student Loan Default Becoming a Top Reason for Exclusion](https://exclusionscreening.com/student-loan-default-becoming-top-reason-exclusion/): Providers are often surprised to learn that a person can be excluded from participation in federal health care programs because... - [Why Should I Screen Against Every State Exclusion List?](https://exclusionscreening.com/screen-every-state-exclusion-list/): The Office of the Inspector General (OIG) issued a Special Advisory Bulletin in May 2013, which states that providers can... - [Who Should Be on my OIG Exclusion Screening List?](https://exclusionscreening.com/oig-exclusion-screening-list/): I. Federal and State Agencies Conducting Audits As many healthcare providers and suppliers have painfully learned over the last year,... - [Home Health and Nursing Home Facilities a Major Target for OIG Enforcement](https://exclusionscreening.com/oig-enforcement-civil-monetary-penalties/): I. Civil Monetary Penalties Twenty-five out of the fifty-five exclusion enforcement actions reported in 2014 have occurred in home health,... - [Must Haves for a Proper Exclusion Screening Process](https://exclusionscreening.com/proper-exclusion-screening-process/): At Exclusion Screening, LLCSM, we know the ins-and-outs of the exclusion screening process. In our opinion, an effective screening process... - [The Administrative Process of Imposing an OIG Exclusion](https://exclusionscreening.com/administrative-process-oig-exclusions/): I. Mandatory OIG Exclusions When the Office of Inspector General (OIG) considers imposing a mandatory exclusion, it sends the individual... - [CMP Liabilities: Why Are Some Much Higher Than Others?](https://exclusionscreening.com/cmp-liabilities-much-higher-others/): A quick review of the Office of Inspector General’s (OIG) exclusion enforcement actions might make one wonder why the Civil... - [Do I Really Need to Screen My Employees and Vendors Each Month?](https://exclusionscreening.com/monthly-screening/): I. OIG Recommends Monthly Screening While there is not a formal regulation that mandates monthly exclusion screening, OIG issued guidance... - [Alert to Florida Providers Regarding Screening](https://exclusionscreening.com/alert-florida-excluded-providers/): I. Florida’s State Exclusion. Excluded Providers Costs OIG Over 2. 7 Million The Office of the Inspector General (OIG) recently... - [CMS Finds Fault with Exclusion Information Sharing Between States](https://exclusionscreening.com/cms-exclusion-information-sharing/): I. Take It from CMS: If You’re Excluded in One State, You’re Excluded in All States Section 6401(b)(2) of the... - [Gary Cantrell Testimony: Failures to Report Adverse Licensing Actions Leads to Gaps in the OIG-LEIE](https://exclusionscreening.com/gary-cantrell-testimony/): HHS/OIG Deputy Inspector General Gary Cantrell testified earlier this year that States are failing to report all of the adverse actions... - [Exclusion Databases: How Difficult Is Screening and Verifying?](https://exclusionscreening.com/screening-exclusion-databases/): I. Which Exclusion Databases Do I Need to Screen? The Office of Inspector General (OIG) recommends that you screen your... - [2015 OIG Work Plan: Prevention of Grant Awards to Excluded Persons and Entities](https://exclusionscreening.com/2015-oig-work-plan/): I. Concerns of the 2015 OIG Exclusion Work Plan The Office of Inspector General (OIG) expressed concern regarding exclusion and... - [OIG Provides Guidance on Disclosures for Conduct Involving Excluded Persons in the Updated Self-Disclosure Protocol](https://exclusionscreening.com/oig-provider-self-disclosure-protocol/): I. Provider Self-Disclosure Protocol: New Guidance Sheds Light on Disclosure On April 17, 2013, the Office of the Inspector General... --- # # Detailed Content ## General Info - Published: 2025-09-06 - Modified: 2025-09-22 - URL: https://exclusionscreening.com/amba/ WElcome AMBA Members Exclusion Screening has been supporting AMBA members in carrying forward the continuity of the medical billing and coding industry for over a decade. With regulations changing constantly, exclusion screening compliance can feel overwhelming. We simplify it with verified, reliable exclusion screening that protects your reputation and your bottom line. Schedule a Free Consultation Safeguard Your Billing Reputation. hbspt. forms. create({ portalId: "4660270", formId: "94a7fe6e-92c9-496e-8e48-ac046a2ef83b", region: "na1" }); Safeguard Your Billing Reputation. You’re never navigating compliance and exclusion screening alone. Your clients trust you to bill correctly and compliantly. We make sure hidden exclusions never put that trust at risk. Fill out the form and we will contact you to demonstrate our solution and discuss pricing. About Us We Understand Your Business, Your Needs, and Understand Law. Exclusion Screening, LLC is the only screening company developed by nationally recognized former Federal prosecutors that provides comprehensive and verified exclusion screening services across all Federal and State exclusion lists. Learn More About Us Frequently Asked Questions What is an OIG Exclusion? Exclusions are final administrative sanctions imposed by the Office of Inspector General for the Department of Health and Human Services (HHS/OIG, or simply OIG) that bar individuals and entities from participating in Federal and State health care programs such as Medicare, Medicaid, CHIPs, and any other program that receives federal funding.   Federal programs are prohibited from paying for items or services provided by excluded parties, and providers that employ or contract with them risk the imposition of civil money penalties and... --- - Published: 2025-09-04 - Modified: 2025-09-22 - URL: https://exclusionscreening.com/first-light/ HOME CARE Welcome, FirstLight Home Care team We’re here to bring you peace of mind by making exclusion screening simple, reliable, and stress-free. Families rely on you for safe, trusted care — and that means every hire must be compliant. One missed exclusion can put your clients, your license, and your reputation at risk. We make it simple, reliable, and cost-effective. So you can focus on caring for people, while we protect your compliance. Schedule a Free Consultation See How Easy Compliance Can Be. hbspt. forms. create({ portalId: "4660270", formId: "c300f8b2-61c7-454d-b15e-2750bb9abc6c", region: "na1" }); See How Easy Compliance Can Be. Caring for people is your mission. Keeping you safe from compliance risks is ours. Our tailored screening solutions safeguard your agency against screening risks, so you can focus on serving families—not fighting compliance battles. Fill out the form and we will contact you to demonstrate our solution and discuss pricing. About Us We Understand Your Business, Your Needs, and Understand Law. Exclusion Screening, LLC is the only screening company developed by nationally recognized former Federal prosecutors that provides comprehensive and verified exclusion screening services across all Federal and State exclusion lists. Learn More About Us Frequently Asked Questions What is an OIG Exclusion? Exclusions are final administrative sanctions imposed by the Office of Inspector General for the Department of Health and Human Services (HHS/OIG, or simply OIG) that bar individuals and entities from participating in Federal and State health care programs such as Medicare, Medicaid, CHIPs, and any other program that receives... --- - Published: 2025-07-10 - Modified: 2025-09-04 - URL: https://exclusionscreening.com/contractor-vendor-screening/ Understanding Obligations, Risks, and Best Practices Contractor & Vendor Screening While many organizations are aware that they have to screen their employees and providers, many are not aware that they also need to be screening their vendors and contractors.   Contact Us Back to What We Do Is it Necessary for Providers to Screen Vendors and Contractors? An issue that arises when healthcare providers have a large pool of contractors, vendors, or agents that they work with from time to time is whether a particular contractor or vendor performs services or provides supplies that are paid “in whole or in part” with funds that are derived from Federal health care benefit program revenues. --- - Published: 2025-07-10 - Modified: 2026-01-08 - URL: https://exclusionscreening.com/exclusion-screening/ Compliance with precise exclusion screening. Exclusion Screening For Employees We offer an exclusion screening service against over 42 separate Exclusion databases including the OIG LEIE, GSA SAM. Contact Us Schedule a Demo Your compliance obligations, our responsibility. We handle all your Federal and State exclusion screening and verification—so you don’t have to. OIG LEIE Database We handle all your Federal and State exclusion screening and verification—so you don’t have to. GSA SAM Database We handle all your Federal and State exclusion screening and verification—so you don’t have to. Over 40 State Databases We handle all your Federal and State exclusion screening and verification—so you don’t have to. We Customize Our Exclusion Screening Service to Address Your Specific Needs Many organizations have different screening needs. At Exclusion Screening, we are focused on meeting your specific needs. Currently, our proprietary software, SAFERTM screens employees, vendors, and contractors through the OIG and SAM Federal Databases, as well as through every State database. When one of these databases is updated, our proprietary software immediately updates our SAFERTM system with the new exclusion information. This helps ensure that each month, that your employees, contractors, and vendors are screened to verify that they have not excluded from participating in Federal and State healthcare programs. Our Commitment to You Exclusion Screening uses its own proprietary software called SAFERTM. This is the most advanced exclusion screening software on the market today. Using complex algorithms, that are constantly changing to be even more precise and efficient, SAFERTM updates daily to add new Federal and State exclusion database information. Currently,... --- - Published: 2025-07-10 - Modified: 2026-01-08 - URL: https://exclusionscreening.com/compliance-hotline/ Compliance Hotline Reduce risk with empowered reporting Created by healthcare industry experts, our Compliance Hotline helps you cultivate an ethically responsible company culture by facilitating active detection. Learn More Schedule a demo multiple reporting modalities Report in confidence Provide several ways for your employees, contractors, vendors, and patients to report potential violations of an organization’s ethical, regulatory, or legal obligations. Call our toll-free telephone report line Compliance Hotline maintains and operates a live reporting service with trained compliance personnel in Washington, DC. Report on an secure online portal Send through your report to our P. O. box. E-mail us your report Incident details may be sent by a concerned individual. Print and fax your report Print and fax a Compliance Hotline incident. Mail us your report Send through your report to our P. O. box. initiate ethical responsibility Why allow pressure to build up in your organization? Organizations can no longer turn a blind eye to unethical business practices, sexual harassment, or any other form of hostility within the workplace. By offering a compliance hotline, your organization shows that they are dedicated to creating an ethically responsible culture within your organization which consistently results in the hiring of better employees and the conducting of better business. Protect your business Our credentials --- - Published: 2025-07-07 - Modified: 2026-01-08 - URL: https://exclusionscreening.com/what-we-do/ Comprehensive Exclusion Screening Solutions. We approach exclusion screening through a provider-focused method. Mitigate risks and ensure compliance with our commitment to precision. Contact Us See our services S. A. F. E. R SAFER (State And Federal Exclusion Registry) is Exclusion Screening, LLC's proprietary database designed to help healthcare providers meet their federal and state exclusion screening obligations Comprehensive Coverage We encompass the OIG's List of Excluded Individuals and Entities (LEIE), the General Services Administration's System for Award Management (GSA/SAM), and all currently available 37 State Exclusion Databases, making us more extensive than other systems. Updated Daily SAFER is updated daily to ensure the most current information, which is more frequent than the monthly updates of the OIG-LEIE and variable state lists. Verification SAFER goes beyond mere exact name matches to include various spellings and nicknames, providing a broader and more accurate search than other databases which may be limited to exact matches. See the difference with Exclusion Screening LLC! We encompass the OIG's List of Excluded Individuals and Entities (LEIE), the General Services Administration's System for Award Management (GSA/SAM), and all currently available 37 State Exclusion Databases, making us more extensive than other systems Schedule a Demo Compliance Hotline A compliance hotline is a critical component of an effective compliance program, specifically pertaining to "Effective Lines of Communication" (Element 4)12. It provides independent reporting paths, often anonymously, for employees and others to directly report violations of federal and state healthcare requirements, such as fraud, waste, or abuse2... . This mechanism... --- - Published: 2025-07-02 - Modified: 2025-09-03 - URL: https://exclusionscreening.com/terms-of-use/ Standard Terms of Use Terms of Use Updated on September 3, 2025 These Terms of Use are incorporated by reference into the Agreement for License of SAFER™ and Screening Services between Exclusion Screening, LLC (“Exclusion Screening”) and the Client. 1. Access Restrictions 1. 1. Access to SAFER™ is limited to designated Permitted Users who must comply with these Terms of Use and the Agreement. 1. 2. SAFER™ data may not be used to determine eligibility for insurance, extend credit, or assess qualifications for licensure. 1. 3. Client may not sublicense, assign, or transfer access to SAFER™ or its contents without prior written consent from Exclusion Screening. 1. 4. All SAFER™ content and reports are for Client’s internal use only and may not be shared with third parties without written authorization from Exclusion Screening. 1. 5. A current list of databases included in SAFER™ is maintained at www. exclusionscreening. com. 1. 6. Permitted Users must not share login credentials, including usernames or passwords, with other individuals. If additional team members require access, the Client must request that Exclusion Screening create individual user accounts for them. 2. Intellectual Property Rights 2. 1. SAFER™ is the exclusive property of Exclusion Screening and is protected under U. S. copyright law and international treaties. 2. 2. Client shall not: Claim ownership of SAFER™ or its components; Reverse-engineer, replicate, or reproduce SAFER™ data or software; Dispute or infringe upon Exclusion Screening’s intellectual property rights. 2. 3. Client acknowledges that Exclusion Screening has invested significant resources in... --- - Published: 2025-07-01 - Modified: 2025-10-28 - URL: https://exclusionscreening.com/schedule-a-demo/ Schedule a Free Consultation We monitor all Federal & State Exclusion Lists HHS OIG GSA SAM. gov State Medicare/Medicaid NPPES NPI Registry OFAC SDN & Non-SDN SSN Death Master File CMS Preclusion Many Others Made for providers in mind. Start protecting your business today with our exclusion screening services. Competitive pricing based on monitoring lists and volumes! Fill out the form and we will contact you to demonstrate our solution and discuss pricing. For customer support, fill out the form and we will get back to you shortly. hbspt. forms. create({ portalId: "4660270", formId: "d0c96c15-b305-455c-a296-55e50f24d4b9", region: "na1" }); Your Referral Keeps Healthcare Safer We’re honored to help organizations maintain compliance and protect patients. If you know another healthcare provider who could benefit from our exclusion screening services, we’d love your referral. --- - Published: 2022-06-15 - Modified: 2025-10-28 - URL: https://exclusionscreening.com/contact/ Contact Us We monitor all Federal & State Exclusion Lists HHS OIG GSA SAM. gov State Medicare/Medicaid NPPES NPI Registry OFAC SDN & Non-SDN SSN Death Master File CMS Preclusion Many Others Made for providers in mind. Start protecting your business today with our exclusion screening services. Competitive pricing based on monitoring lists and volumes! Fill out the form and we will contact you to demonstrate our solution and discuss pricing. Customer Support hbspt. forms. create({ portalId: "4660270", formId: "259b0f0e-d266-4199-ab98-724caa62df2f", region: "na1" }); For support, fill out the form and we will get back to you shortly. hbspt. forms. create({ portalId: "4660270", formId: "d0c96c15-b305-455c-a296-55e50f24d4b9", region: "na1" }); Your Referral Keeps Healthcare Safer We’re honored to help organizations maintain compliance and protect patients. If you know another healthcare provider who could benefit from our exclusion screening services, we’d love your referral. --- - Published: 2022-06-15 - Modified: 2025-10-28 - URL: https://exclusionscreening.com/about/ We Understand Your Business, Your Needs, and Understand Law. Exclusion Screening, LLC is the only screening company developed by nationally recognized former Federal prosecutors that provides comprehensive and verified exclusion screening services across all Federal and State exclusion lists. Our history in healthcare We have been in health care for a long time – Robert in 1984 as a Hospital Administrator and Paul in 1996 with the passage of HIPAA – and we know first hand that most providers are committed to quality care and compliance with the rules. But what happens if a provider is confronted with rules or regulations that are difficult to understand, costly, and almost impossible to comply with (even without regard to the expense)? The lack of any reasonable solution weighed on us and we simply couldn’t let it go. Was it possible, we kept asking, that such a fundamental obligation could be so difficult to comply with? Well, as you may have guessed, we never found a solution to the problem, so we went ahead and created one! As so let us welcome you to Exclusion Screening, LLC. What We Do Screening, S. A. F. E. R. SAFER allows you to perform search and verification using management tools, advanced reporting using online search, batch processing, or real-time access using API and web service integration. SAFER is built with the ability to scale horizontally to process large volumes of data. Compliance Hotline Our mission is to enable open lines of communication so you can address... --- - Published: 2022-06-15 - Modified: 2026-01-08 - URL: https://exclusionscreening.com/ Founded by healthcare attorneys with 70 + years of Combined Experience Peace of Mind, Guaranteed. Exclusion Screening by the Experts Who Wrote the Rules. We make exclusion screening simple, reliable, and guaranteed—trusted by practices and organizations nationwide. Schedule a Free Consultation our responsibility We handle your compliance so you can focus on your practice We meticulously handle all your Federal and State exclusion screening and verification, ensuring you complete compliance with zero effort on your part. Our credentials Verification We emphasize verification that confirms identity, using multiple data points and documented logic to determine whether a match is truly the same individual or entity—reducing false positives and false negatives. Scalable We scale by compliance accuracy—not inefficiency. Designed with all organizations in mind, we frame cost as proportional to risk/need, not one-size-fits-all. Cost-Effective Exclusion Screening delivers compliance value without unnecessary cost by focusing resources where they matter most and eliminating avoidable expense. End-to-End Compliance Our Solutions Support your organization with a comprehensive compliance program by addressing risk across all areas. Identify issues early, maintain oversight, and meet regulatory expectations with confidence. What we do See the difference Employee Screening Screen employees and candidates against exclusion lists to support regulatory compliance. We offer single searches and scalable options. See Exclusion Screening for Employees Vendor and Contractor Screening Reduce regulatory risk and ensure compliant business relationships. See Exclusion Screening for Vendors Compliance Hotline A confidential reporting channel for employees and partners to report concerns. See Compliance Hotline Comprehensive Coverage The lists that matter... --- - Published: 2020-08-14 - Modified: 2025-08-05 - URL: https://exclusionscreening.com/privacy-policy-2/ Standard Terms of Use Privacy Policy These Terms of Use are incorporated by reference into the Agreement for License of SAFER™ and Screening Services between Exclusion Screening, LLC (“Exclusion Screening”) and the Client. 1. Access Restrictions 1. 1. Access to SAFER™ is limited to designated Permitted Users who must comply with these Terms of Use and the Agreement. 1. 2. SAFER™ data may not be used to determine eligibility for insurance, extend credit, or assess qualifications for licensure. 1. 3. Client may not sublicense, assign, or transfer access to SAFER™ or its contents without prior written consent from Exclusion Screening. 1. 4. All SAFER™ content and reports are for Client’s internal use only and may not be shared with third parties without written authorization from Exclusion Screening. 1. 5. A current list of databases included in SAFER™ is maintained at www. exclusionscreening. com. 1. 6. Permitted Users must not share login credentials, including usernames or passwords, with other individuals. If additional team members require access, the Client must request that Exclusion Screening create individual user accounts for them. 2. Intellectual Property Rights 2. 1. SAFER™ is the exclusive property of Exclusion Screening and is protected under U. S. copyright law and international treaties. 2. 2. Client shall not: Claim ownership of SAFER™ or its components; Reverse-engineer, replicate, or reproduce SAFER™ data or software; Dispute or infringe upon Exclusion Screening’s intellectual property rights. 2. 3. Client acknowledges that Exclusion Screening has invested significant resources in developing and maintaining the SAFER™ platform... --- --- ## Topical deep dives - Published: 2026-01-06 - Modified: 2026-01-07 - URL: https://exclusionscreening.com/state-exclusion-databases-medicaid-exclusion/ - Categories: Medicaid Enforcement - Tags: Databases, Exclusion, Medicaid, State, State Medicald Exclusion Databases Map of the States with a Separate Medicaid Exclusion List Click on your state to view their Medicaid exclusion list. Note that the states in grey do not have a separate list. There are a total of 45 separate Medicaid exclusion lists, published by 44 states. This includes Washington, D. C. Note that Washington State publishes two separate exclusion lists — accounting for the extra count. The focus of this article is to help providers identify which States have a separate Medicaid exclusion list, how they are different from the federal exclusion lists, and the effects on screening. I. Medicaid Exclusion Exclusion Screening, LLC conducts monthly checks of our clients’ employees, contractors, and vendors against the OIG-LEIE, GSA-SAM, and all available State Exclusion Lists. Most providers understand that they have an obligation to check their employees, contractors, and vendors against the OIG-LEIE prior to hiring and monthly thereafter. Fewer providers are aware of their obligation to screen their individual state exclusion list if their state maintains such a list. CMS directed State Medicaid Directors to remind all providers that they have an obligation to search their state list whenever they search the LEIE. 1 In addition, many states require providers when they enroll or re-enroll in the Medicaid program to certify that no employee or contractor is excluded from participation in any state. This requirement echoes the Affordable Care Act (ACA) Section 6501, which states that if a provider is excluded in one state, he or she is excluded in... --- - Published: 2026-01-02 - Modified: 2026-01-02 - URL: https://exclusionscreening.com/a-providers-guide-to-washington-state-medicaid/ - Categories: Medicaid Enforcement This guide is intended to assist Apple Health providers on exclusion and sanction screening obligations for anyone whose role could affect Medicaid billings or deliverables — clinical and non-clinical — and describes how to screen, document, remediate, and report matches. This guide is intended to assist Apple Health providers on exclusion and sanction screening obligations for anyone whose role could affect Medicaid billings or deliverables — clinical and non-clinical — and describes how to screen, document, remediate, and report matches. Washington’s Medicaid program, also known as Apple Health imposes significant exclusion and sanction-screening obligations on providers. In practice this means providers must screen employees, contractors, volunteers, subcontractors and other persons or entities who touch Medicaid billings or services against Washington’s HCA/DSHS termination and exclusion lists and the federal exclusion sources (OIG’s LEIE and SAM) — typically at hire/engagement and monthly thereafter.   Authorities, Definitions, and Quick Links Washington Administrative Code (WAC): WAC 182-502-0030; WAC 388-113-0020; WAC 388-113-0030; WAC 388-71-0540 (state rules governing termination and exclusion). Federal law/regulation: 42 CFR Part 1001 (OIG exclusion authorities); Affordable Care Act §6501 (if excluded in one state, excluded everywhere for Federal healthcare programs). Federal lists: OIG List of Excluded Individuals/Entities (LEIE); System for Award Management (SAM) exclusions. State lists: Apple Health has two provider termination and exclusion lists. Washington Health Care Authority Provider Termination and Exclusion list(HCA); Department of Social and Health Services social services provider listing (DSHS). What are the Basic Washington Medicaid Exclusion Screening Requirements? Washington is one of the forty-five states and the District of Columbia that maintains its own separate Medicaid Exclusion List. These lists generally serve the unified purpose of barring sanctioned individuals and entities from participating in the state’s Medicaid program.   Providers must screen all employees and... --- - Published: 2025-12-30 - Modified: 2025-12-30 - URL: https://exclusionscreening.com/who-can-request-an-exclusion-waiver/ - Categories: Effect Of An Exclusion Authorized Requester Only the administrator of a Federal or state health care program (e. g. , Medicare or Medicaid director) can request an exclusion waiver. The request cannot come directly from the excluded individual or entity. The administrator must be “directly responsible” for administering the program under specific, limited circumstances.   Typically, the process involves the excluded provider submitting the request to an agency administrator, who then forwards it to the Office of Inspector General (OIG). The OIG’s authority to grant a waiver is outlined in 42 C. F. R. § 1001. 1801, et seq. , and the requirements vary depending on whether the exclusion is mandatory or permissive. Obtaining a waiver is generally considered difficult, therefore, even though states can request waivers, most don’t because: The administrative process is complex and slow. They can face scrutiny from the OIG or auditors. It’s usually easier and safer to find another provider or wait for reinstatement. Conditions for Requesting a Waiver There are two types of OIG Exclusions – Mandatory and Permissive, each with separate conditions for requesting a waiver.   Mandatory Exclusions are identified in Sections 1128(a)(1) – 1128(a)(4) of the Social Security Act (SSA), (42 U. S. C. §1320a-7(a)(1)-(4)), and they are imposed as a result of convictions for program fraud, patient abuse, and certain drug offenses.   Permissive exclusions, on the other hand, are discretionary and can be imposed for a broad range of conduct. These are identified in §1128(b)(1)–§1128(b)(16) and §1156 of the Act. Mandatory Exclusion Waiver... --- - Published: 2025-12-30 - Modified: 2025-12-30 - URL: https://exclusionscreening.com/compliance-hotlines-are-crucial-in-healthcare/ - Categories: Compliance Hotlines Compliance hotlines are crucial in healthcare because they directly support patient safety, legal protection, and organizational integrity. Healthcare is one of the most heavily regulated industries in the U. S. , and even small compliance failures can lead to patient harm, financial penalties, and loss of trust. A hotline gives employees a safe way to speak up before issues escalate. Early detection of fraud, abuse, and errors Healthcare organizations are susceptible to fraud, abuse, and errors due to the complexity and reliance on human regulation. There are billing mistakes, documentation errors, fraud or improper coding, and violations of Stark Law, Anti-Kickback Statute, HIPAA, etc.   Because hotlines are usually the first place that people go to report, they can prevent the issues from reaching regulators. Hotlines deescalate these issues from becoming governmental investigations, OIG penalties, and even public scandals.   Protects patients and supports safety Past hotline reports often include topics on unsafe clinical practices, patient mistreatment, protocol violations, medication errors, and a plethora of other safety issues that may have gone unnoticed. Employees will often report safety concerns anonymously if they fear retaliation. A hotline can literally prevent patient harm, and past hotline reports are proof that these issues are common. Without a healthcare compliance hotline, how many of these issues go unspoken?   Encourages a “speak-up culture” Healthcare workers often hesitate to report concerns to supervisors due to fear of retaliation, power dynamics, and even the uncertainty on what can you even report. Employees may question what counts... --- - Published: 2025-12-18 - Modified: 2025-12-18 - URL: https://exclusionscreening.com/exclusions-can-be-devastating-for-small-practices/ - Categories: Effect Of An Exclusion Exclusions from participation in federal and state healthcare programs represent a significant and often devastating threat to healthcare providers, especially small practices. These administrative sanctions are designed to protect government programs and beneficiaries by barring individuals and entities who pose risks. However, failing to comply with exclusion screening obligations can lead to severe financial and operational damage. This article will identify the risks and how best to avoid them.   The Broad Reach of An Exclusion's Impact: The Payment Prohibition The core of the damage inflicted by an exclusion is the "payment prohibition". This means that federal healthcare programs, including Medicare, Medicaid, and TRICARE, are prohibited from paying for any item or service furnished, directly or indirectly, by an excluded individual or entity. This prohibition is exceptionally broad, extending far beyond direct patient care to encompass a wide array of services and personnel within a practice: Management, administrative, or leadership roles. Support and nursing services, even if not directly billed, such as preparing surgical trays or inputting prescription information. Claims processing and information technology. Transportation services, including ambulance drivers or dispatchers. Selling, delivering, or refilling orders for medical devices or equipment. Even unpaid volunteers can trigger overpayment and civil money penalty (CMP) liability if their services are not "wholly unrelated to Federal Health Care Programs". Furthermore, providers like laboratories, imaging centers, and pharmacies are obligated to ensure that ordering or prescribing physicians are not excluded at the point of service. Failure to do so also violates the payment prohibition. This... --- - Published: 2025-12-18 - Modified: 2026-01-05 - URL: https://exclusionscreening.com/what-does-it-mean-to-be-on-an-exclusion-list/ - Categories: Effect Of An Exclusion Being on an exclusion list means that an individual or entity has been barred from participating in a sponsored benefit program, often as a result of a final administrative action taken by Federal or State agencies. This is one of the most severe administrative remedies that can be imposed on an individual or entity. The primary consequence of being on an exclusion list is a payment prohibition. Federal healthcare programs, including Medicare, Medicaid, and TRICARE, are prohibited from paying for any item or service furnished directly or indirectly by an excluded individual or entity. This prohibition is an absolute ban on all federal program compensation. In the context of healthcare, exclusions serve to protect beneficiaries and safeguard the financial integrity of Federal healthcare benefit programs. An excluded party is deemed, as a matter of law, to pose an unacceptable risk to the integrity of the program and to the beneficiaries it serves. Types and Reasons for Exclusion Exclusions generally come in two types, mandatory and permissive, and are typically triggered by specific conduct or adverse actions. 1. Mandatory Exclusions: The Office of Inspector General (OIG) is required by law to exclude individuals and entities if they fall into one of four categories, typically related to criminal convictions: A conviction related to the delivery of an item or service under a Federal or State healthcare benefit program. This includes any type of conviction, whether misdemeanor or felony. A conviction related to the abuse or neglect of a patient in connection with... --- - Published: 2025-12-12 - Modified: 2025-12-12 - URL: https://exclusionscreening.com/how-providers-can-check-oig-exclusions-on-their-own/ - Categories: Exclusion Screening Basics, Providers Guides - Tags: How to Check OIG Exclusions This guide helps ensure compliance by verifying that individuals and entities are not excluded from participation in federal healthcare programs (Medicare, Medicaid, etc.) using the OIG’s online lookup tool. This guide helps ensure compliance by verifying that individuals and entities are not excluded from participation in federal healthcare programs (Medicare, Medicaid, etc. ) using the OIG’s online lookup tool. This guide also dives deep into how a provider can screen the OIG’s look up tool on their own when necessary and the limitations of the online search tool. Our recommendation is to use a screening provider to screen other lists for best practice. Step-by-Step Guide: Check OIG Exclusions using the OIG’s Online Search Tool Access the Lookup Tool on the Officer of Inspector General (OIG)’s Website https://exclusions. oig. hhs. gov. You’ll see two search options in the Exclusions Database. The federal exclusion list is maintained and updated monthly by the OIG, known as the List of Excluded Individuals and Entities (LEIE). The LEIE is the primary federal online searchable database for healthcare providers to check exclusion statuses. Online Searchable Database Providers can manually input names of the entity or the individual they suspect into the website for searching, but they are typically limited (e. g. , to 5 individuals or 4 entities at a time). Downloadable LEIE Database Providers can download the entire LEIE list in Excel format from the OIG's website. This method presents significant challenges for many providers, especially mid-sized or large organizations. Providers would need to compare the list of your employees, vendors, and contractors against the downloaded LEIE spreadsheet, however this method is cumbersome and prone to errors. There are cross-referencing challenges with the nearly... --- - Published: 2025-10-27 - Modified: 2026-01-05 - URL: https://exclusionscreening.com/top-5-challenges-in-exclusion-monitoring-and-how-to-solve-them/ - Categories: Exclusion Screening Basics Exclusion monitoring is a mandatory and complex compliance function critical to minimizing liability risks for healthcare providers. The difficulty inherent in the process itself poses the most significant challenges to effective monitoring. 1. The Sheer Volume of Required Databases Providers must screen against a complex and growing web of lists, including the OIG’s List of Excluded Individuals and Entities (LEIE), the GSA’s System for Award Management (GSA/SAM), and all relevant state exclusion lists. Due to "implied screening obligations" (such as in Texas and Louisiana) and the ACA rule that exclusion in one state Medicaid program means exclusion in all, screening all available state lists (currently 38 to 41, plus D. C. ) is often necessary. Solution Providers must adopt a comprehensive approach, screening the LEIE, GSA/SAM, and all available State exclusion lists monthly. The most practical and cost-effective method is outsourcing to a third-party vendor that integrates all these lists into one process. 2. Mandatory Monthly Screening Frequency Exclusion status is not static; it is subject to change at any time, often due to the resolution of pending licensing or criminal matters. The OIG has unequivocally stated that screening monthly "best minimizes potential overpayment and CMP liability". Finding the dedicated time and manpower for consistent monthly checks is difficult, particularly for smaller offices Solution Implement a robust, non-delegable monthly protocol where screening occurs upon hire and every 30 days thereafter. Outsourcing this task is highly recommended, as it is difficult, time-consuming, and prone to error when attempted manually. 3. Limited... --- - Published: 2025-09-30 - Modified: 2025-10-24 - URL: https://exclusionscreening.com/what-to-do-if-you-have-a-confirmed-exclusion/ - Categories: Effect Of An Exclusion - Tags: post exclusion https://videopress. com/v/Vw4Qfthb? resizeToParent=true&cover=true&posterUrl=https%3A%2F%2Fexclusionscreening. com%2Fwp-content%2Fuploads%2F2025%2F09%2FExcluded-Employee. png&preloadContent=metadata&useAverageColor=true Dive into what to do when you find an excluded employee Finding out that an employee, vendor, contractor, or volunteer has a confirmed exclusion is a serious compliance emergency. Since Federal healthcare programs absolutely will not pay for any item or service furnished directly or indirectly by an excluded party, your organization faces major financial and legal risks. Here is a simplified guide on the options and steps you must take to address this problem. For a more detailed guide visit our other article I Have a Confirmed Exclusion What are my Options. Step 1: Stop the Bleeding (Immediate Action) The first priority is halting the violation immediately to minimize overpayment and Civil Money Penalty (CMP) exposure. End the Relationship Immediately Remove the excluded party right away. This is the best action a practice can take to minimize liability risks. Exclusions are serious administrative actions, often based on fraud, patient abuse, or drug convictions, posing a direct risk to your organization and its patients. Contact a Lawyer Immediately consult with healthcare counsel to determine the best legal strategy for proceeding. Preserve Documentation Keep records of how the problem was discovered and all corrective actions you take. Step 2: Determine the Damage Every exclusion case is unique, so you need to investigate the specifics to figure out your exact financial exposure. Ask yourself these nine critical questions: Is the excluded party a new employee or a long-time employee? (This determines the length of the violation. )... --- - Published: 2025-04-22 - Modified: 2025-09-11 - URL: https://exclusionscreening.com/why-is-it-necessary-to-screen-the-nppes-registry/ - Categories: Exclusion Screening Basics - Tags: Nppes, Nppes Registry, Registry We are sometimes asked, “Why do you screen against the National Plan and Provider Enumeration System (NPPES). ”  That is a great question. Many healthcare providers are only familiar with the exclusion database maintained by the Department of Health and Human Services (HHS), Office of Inspector General (OIG) – known as the List of Excluded Individuals and Entities (LEIE). Nevertheless, it is important to remember that the LEIE is only one of many Federal and State exclusion databases that a healthcare provider or supplier should be monitoring on a monthly basis. For example, the U. S. General Services Administration (GSA) maintains the System of Award Management (SAM), a registry of individuals and entities that have been excluded or debarred from doing business with the government. In addition to these Federal databases, approximately 42 states currently maintain lists of individuals and entities that have been excluded from participating in the Medicaid and CHIP programs. At Exclusion Screening, we screen against these “core” exclusion databases (the LEIE, the GSA-SAM, and the complete list of State Medicaid exclusion lists). Notably, we don’t stop there. We also screen against a number of additional Federal databases (such as the NPPES), that we have identified as essential in: Reducing a healthcare provider's level of CMP risk; Protecting Federal health care program beneficiaries; and, Safeguarding the financial integrity of these indispensable Federal health care programs. This article examines the NPPES in more detail and discusses its program integrity role and functions in the overall screening process. I.... --- - Published: 2025-04-15 - Modified: 2025-08-07 - URL: https://exclusionscreening.com/practices-need-hotlines-in-their-compliance-program-2/ - Categories: Compliance Hotlines The OIG’s November 2023 Compliance Guidance The OIG’s November 2023 Compliance Guidance lists 7 elements of an effective compliance program. Compliance Hotlines are a critical component of element 4 - “Effective Lines of Communications. ” Written Policies and Procedures Compliance Leadership and Oversight Training and Education Effective Lines of Communication with the Compliance Officer and Disclosure Program Enforcing Standards: Consequences and Incentives Risk Assessment, Auditing, and Monitoring Responding to Detected Offenses and Developing Corrective Action Initiatives Element 4—Effective Lines of Communication states: There should be several independent reporting paths for an employee to directly report violations of Federal and State health care requirements, such as fraud, waste or abuse,  At least one should be independent of the business to facilitate anonymous reporting  Such as through a hotline, a website, an email address, or a mailbox.   Compliance Hotline allows for employees to make reports through all of those modalities. 2024 Report on Occupational Fraud by the Association of Certified Fraud Examiners (ACFE) AFCE publishes a yearly report on occupational fraud. The 2024 report (attached) has the following excerpts, which demonstrate the importance of hotlines:  Under the heading “How is Occupational Fraud Initially Detected,” ACFE provides this data:  43% of the reports of occupational fraud were made in the form of “tips. ” Reports of occupational fraud were three times as likely to be made in the form of tips than any of form. 14% of reports came from internal audits and 13% for management reviews. Drilling down, ACFE found that... --- - Published: 2024-06-19 - Modified: 2025-10-28 - URL: https://exclusionscreening.com/a-provider-guide-to-new-york-medicaid-exclusion-screening/ - Categories: Providers Guides This article focuses on helping providers understand New York Medicaid exclusion screening law, and its exclusion screening requirements so that they can avoid the risks associated with employing or doing business with excluded parties. A Provider Guide to New York Medicaid Exclusion Screening The New York Medicaid Program is prohibited by State law from paying for items or services furnished excluded parties. The State ban, which is separate and independent of federal law, is enforced primarily through mandated provider exclusion screening requirements and the threat of imposing overpayment liability, penalties, and exclusion or termination for providers that fail to screen and violate the payment ban. This article focuses on helping providers understand New York Medicaid exclusion screening law, and its exclusion screening requirements so that they can avoid the risks associated with employing or doing business with excluded parties. New York Determines Who Can Provide Services to its Medicaid Program New York is responsible for the administration of its Medicaid program. It sets the standards and qualifications for its participating providers and is authorized to exclude providers from participation if the action is supported by either State or Federal law. The State ensures that its participating providers have not been excluded from participation in State or Federal health care programs through the enactment and enforcement of exclusion screening rules and obligations. Basis for Exclusion in New York Exclusions are imposed in New York for engaging in “unacceptable practices under the medical assistance program. ” This includes employing excluded parties, submitting claims on behalf of excluded parties, and accepting payment services provided by an excluded party as the basis for an exclusion. Other conduct that is considered an unacceptable practice includes, but is not limited... --- - Published: 2024-04-26 - Modified: 2025-08-19 - URL: https://exclusionscreening.com/summary-of-alabama-medicaid-exclusion-and-sanction-screening-requirements/ - Categories: Medicaid Exclusion Summaries This short question and answer summary will help providers understand and comply Alabama’s exclusion and sanction screening rules and regulations. Alabama’s Medicaid Program will not pay for any item or service furnished by, or at the medical direction of, an excluded party. To enforce this payment prohibition, it imposes exclusion and sanction screening requirements on providers, and those that fail to fulfill their screening obligations, risk the imposition of overpayments and civil money penalties. This short question and answer summary will help providers understand and comply Alabama’s exclusion and sanction screening rules and regulations. What are the Basic Alabama Medicaid Exclusion Screening Requirements? Prior to hiring and monthly thereafter, providers in Alabama are required to screen all employees, vendors, and contractors that contribute to the submission of any Medicaid claims with the Alabama Medicaid Exclusion List, the Office of Inspector General’s List of Excluded Individuals and Entities (LEIE), and the General Services Administration, System for Award Management’s debarment list (GSA/SAM). What is the effect of an exclusion from participation in Alabama Medicaid? Since Alabama will not pay for any item or service furnished either directly or indirectly by an excluded party, excluded parties are essentially banned from all participation in its Medicaid program. The payment prohibition extends to support services that are not directly billable such as nursing care and the preparation of surgical trays; to indirect services such as inputting prescription information; and to administrative and management duties. The ban also applies if the excluded party provided the item or service indirectly, and it extends to all methods of reimbursement (whether bundled, fee-for-service, or other). (Alabama Administrative Code, Rule... --- - Published: 2024-04-22 - Modified: 2025-09-12 - URL: https://exclusionscreening.com/oig-exclusion-vs-cms-preclusion-list/ - Categories: Preclusion List Screening - Tags: Actions, Cms, Cms Preclusion List, Preclusion OIG Exclusion List vs. CMS Preclusion List Since the CMS Preclusion list was announced in April 2018, and then published in January 2019, there has been confusion and questions regarding the list, its differences from the OIG Exclusion List, the size of the list, and who has access. Unfortunately, the publication of the list has added further complexity to the already complicated terrain of health care compliance. For that reason, the below article is designed to be a OIG Exclusion List vs. CMS Preclusion List comparison while also providing addition insight into the CMS Preclusion List. If you are interested in additional information regarding the CMS Preclusion List, click here to read our article titled “What to Know About the New CMS Preclusion List. ” Overview on the OIG Exclusion List and the CMS Preclusion List The OIG Exclusion List is a registry of individuals and entities that have been excluded from participation in Federal health care programs. Exclusion may be mandatory in nature or permissive, depending based on the underlying adverse action. The CMS Preclusion List is a registry of all health care providers, suppliers, and prescribers who are precluded from receiving reimbursement for Part C Medicare Advantage items and services or Part D drugs that are provided or prescribed to Medicare beneficiaries. Purpose If a health care provider, supplier, or other entity is on the OIG Exclusion LIST, the excluded party cannot provide care or services to Medicare and / or Medicaid beneficiaries. Nor can the excluded party work... --- - Published: 2024-04-16 - Modified: 2025-09-12 - URL: https://exclusionscreening.com/oig-exclusion-waiver/ - Categories: Exclusion Screening Basics - Tags: Exclusion, What Is And Exclusion We have previously discussed that once a provider is excluded he may not furnish items or services paid for by the the Federal health care programs until he is eligible to apply for reinstatement and the Office of the Inspector General (OIG) approves this reinstatement request. The one exception to this general rule is that OIG does have the authority to grant certain excluded individuals or entities an exclusion waiver. 1  What is an Exclusion Waiver? Waivers permit certain excluded individuals or entities to be eligible for payment by Medicare, Medicaid, and all other Federal health care programs for specific items and services defined in the scope of the waiver. A waiver will explicitly define the scope of services an excluded individual or entity may provide. It may permit payment under the Federal health care programs for covered services like office visits, home visits, and hospital visits. It may also permit hospital stays, medical tests, procedures, and/or equipment ordered by the provider, and drugs, devices, and/or other items prescribed by the provider. Who may apply? Waivers are only available for excluded providers that are the only physician or source of an essential specialized service within a specific geographic location or institution.   A waiver will not and cannot be granted to a person excluded due to patient neglect or abuse. How may a provider request an exclusion waiver? A waiver may only be requested by the administrator of a Federal or state health care program. What payment is provided under an exclusion waiver? When... --- - Published: 2024-03-21 - Modified: 2025-09-12 - URL: https://exclusionscreening.com/california-exclusion-screening-requirements/ - Categories: Medicaid Enforcement - Tags: California, California Exclusion, Exclusion What are the California Exclusion List Screening requirements? The Medi-Cal Program will not pay for any item or service furnished directly or indirectly by individuals or entities that have been excluded or suspended from the Medi-Cal Program or that have been placed on the Office of Inspector General’s Exclusion List. This results in a broad “suspension” for any providers that have found themselves on this list which is enforced by the California Department of Health Care Services (DHCS). This article will discuss what an exclusion is, how providers wind up on this list, how they are impacted by these regulations and the exclusion screening obligations they impose; the risks of compliance failures; and it will suggest best practices to help providers comply with their obligations and avoid those risks and understand how to screen for exclusions in California. What is a Medicaid Exclusion?   “Exclusions” are final administrative action by a State or Federal agency that bars an individual or entity from participating in one of its benefit programs. When a State forecloses participation in its Medicaid programs, that action is often referred to as a “Medicaid Exclusion. ” Similarly, when the Department of Health and Human Services (HHS), Office of Inspector General (OIG) bars participation in Medicare program, that is commonly referred to as a “Medicare Exclusion. ”  Medi-Cal Exclusions are posted on database maintained on the website, and Medicare Exclusions are posted on the OIG’s “List of Excluded Individuals and Entities” (LEIE) which is maintained on its website. Who Gets Excluded From... --- - Published: 2024-02-28 - Modified: 2025-09-12 - URL: https://exclusionscreening.com/pennsylvania-exclusion-screening/ - Categories: Medicaid Enforcement, Providers Guides - Tags: Exclusions, Pannsylvania, Pennsylvania Exclusions The Pennsylvania Precluded Provider List, commonly referred to as “Pennsylvania Medicheck ,” identifies individuals and entities who have been excluded from participating in the State’s Medicaid Program. It is similar to the OIG’s List of Excluded Individuals and Entities (LEIE) in that healthcare programs are prohibited from paying for services furnished by barred entities, and that claims which violate the payment prohibition can result in the serious overpayments and civil money penalties, but the two list differ in a number of important ways – such as their provider screening requirements. The focus of this article is to help Pennsylvania providers understand their screening obligations, the risks to providers that fail to meet them, and how providers can easily fulfill their screening obligations and avoid those risks. I. How and Why are Providers Listed on the Precluded Provider and the OIG’s Excluded Provider List? A. Overview of the Pennsylvania Precluded Provider List – Pennsylvania Medicheck. The Pennsylvania Department of Human Services has the authority to terminate providers from the State Medical Assistance (or Medicaid) Program. 55 Pa. Code § 1101. 77(a). The department is also required to maintain the list of all terminated providers in Pennsylvania’s “Medicheck (Precluded Provider) List. ” 55 Pa. Code § 1101. 77(e). Since all terminated providers are on the Pennsylvania Precluded Provider List the terms preclusion and termination are used interchangeably in this article. The database can be searched online at: https://www. humanservices. state. pa. us/Medchk/MedchkSearch/Index. The principal reasons for provider terminations and subsequent placement on the Pennsylvania... --- - Published: 2024-02-19 - Modified: 2025-09-11 - URL: https://exclusionscreening.com/different-exclusion-lists/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Lists, Screening, State, State Exclusion Screening Lists Exclusions and debarments are powerful administrative sanctions imposed by Federal and State agencies. They are intended to protect their programs and the beneficiaries they serve by barring the participation of individuals and entities who pose risks to them. Sanctioned parties are placed on lists by the agencies that impose them, and providers that employ or contract with entities on those lists risk both overpayment and civil money penalty liability. The Office of Inspector General’s “List of Excluded Individuals and Entities” (LEIE), the General Service Administration’s Suspension and Debarment List (GSA/SAM), and State Exclusion Lists are the sanction lists have the greatest impact on healthcare providers. The focus of this article is to help providers understand what they represent, the differences between them, and how to determine their screening obligations with respect to each. The List of Excluded Individuals and Entities – or “LEIE” What is the “List of Excluded Individuals/Entities” – or LEIE? The Office of Inspector General for the Department of Health and Human Services (HHS/OIG, or OIG) has the authority to exclude individuals and entities from participating in federal health care programs.  The List of Excluded Individuals/Entities (LEIE) identifies all persons and legal entities currently under an exclusion sanction, and providers must ensure that they don’t employ or contract with anyone on the list. The LEIE currently has 78,927 entries.  It is maintained and updated monthly by the OIG, and it can be accessed on the OIG’s website. The LEIE can be searched directly on the website or... --- - Published: 2024-01-16 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/unlocking-gsa-sam-mystery/ - Categories: Effect Of An Exclusion, Providers Guides - Tags: Gsa, Gsa Sam, Sam The importance of screening employees, vendors and contractors against available federal and State exclusion databases cannot be overemphasized. Despite the best efforts of the Department of Health and Human Services (HHS), Office of Inspector General (OIG), “exclusion screening” remains perhaps the least appreciated compliance risk faced by many small and mid-sized healthcare providers and suppliers. To the extent that a health care provider has, in fact, taken steps to properly screen its staff and contractors, many have restricted their reviews to periodic screens of the OIG’s List of Excluded Individuals and Entities (LEIE), and their State’s list of parties excluded from participation in Medicaid and other state-funded health care programs. Unfortunately, screening against these databases isn’t sufficient to identify individuals and entities that may have been excluded, suspended or debarred from doing business with other federal agencies and the non-Medicare programs they administer. For the reasons set out in this article, insurance payors, health care providers and suppliers should also screen the General Services Administration’s (GSA’s) System for Award Management (SAM) database to ensure that the individuals and entities they employ or do business with have not been suspended or debarred from doing business with certain federal agencies and the programs they administer. This article also examines the role of the GSA’s SAM Database with respect to screening for excluded, suspended and debarred individuals and entities. I. Historical Overview of the GSA’s System for Award Management (SAM) Database: Today’s GSA’s SAM database has evolved from humble beginnings over the last... --- - Published: 2023-11-17 - Modified: 2025-12-02 - URL: https://exclusionscreening.com/overview-of-the-medi-cal-suspended-and-ineligible-provider-list/ - Categories: Medicaid Enforcement California's Medi-Cal Suspended and Ineligible Provider List is Designed to Safeguard Beneficiaries and Protect the Financial Integrity of the Medi-Cal Program. Most healthcare providers and suppliers in the State of California are aware that exclusions imposed by the Department of Health and Human Services, Office of Inspector General (OIG) effectively prevent an excluded individual or entity from participating in Federal healthcare programs. However, they may not fully appreciate the fact that employing or doing business with an excluded individual or entity can result in the imposition of significant financial penalties. Many healthcare providers are also unaware that state regulators have broad, independent authorities with respect to California’s suspension regulations and sanctions enforcement. This article focuses on helping providers understand the scope and impact of Medicaid exclusion screening activities around the country, focusing on California’s Medi-Cal Suspended and Ineligible Provider List. We also discuss the specific regulatory and contractual obligations that California now requires if you or your practice are a Medi-Cal participating provider. Finally, we will review the impact of violating these mandates and how to reduce your company’s level of risk when providing health care services under the Medi-Cal program. I. Brief History of the Medicaid Program: On July 30, 1965, President Lyndon B. Johnson signed the “Social Security Amendments of 1965” into law, thereby establishing the Medicare and Medicaid programs. Broadly speaking, under the Medicare program, qualified individuals ages 65 or older (and younger individuals who are disabled), are eligible to receive medical care that is paid for... --- - Published: 2023-11-14 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/providers-guide-to-oig-exclusions/ - Categories: Providers Guides - Tags: Exclusions, Oig, Oig Exclusions A Provider’s Guide to OIG Exclusions: Federal Exclusion Regulations and Enforcement Authorities, and How Providers Can Avoid Risk with Proper Exclusion Screening This article is an updated version of “A Provider’s Guide to OIG Exclusions: Federal Exclusion Regulations and Enforcement Authorities, and How Providers Can Avoid Risk with Proper Exclusion Screening. ” The original article was published in The Journal of Medical Practice Management (Volume 34, Number 5, March/April, 2019 and Volume 34, Number 6, May/June Issue, 2019. Office of Inspector General (OIG) exclusions are one of the most powerful weapons available to the law enforcement in its efforts to fight healthcare fraud. Individuals and entities subject to OIG exclusions are barred from participation in all Federal healthcare benefit programs, resulting in a payment prohibition on all items and services they provide, whether directly or indirectly. Additionally, providers that employ or contract with excluded individuals or entities risk the imposition of civil money penalties, overpayment liability, and even potential exposure under the False Claims Act. However, even though OIG exclusions are one of law enforcement’s oldest tools, many providers often fail to appreciate their compliance obligations and the risks associated with employing or contracting with excluded individuals or entities. Indeed, many providers make only minimal efforts to screen their employees and contractors to ensure compliance—and some make no effort at all. This article seeks to educate providers on the existing legal and regulatory framework, the risks and potential consequences of a failure to comply with those laws and regulations, and how... --- - Published: 2023-11-10 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-exclusion-list/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Oig, What Is An Oig Exclusion OIG Exclusions are powerful enforcement sanctions that bar an individual or entity from any participation in Federal and State health care benefit programs. Programs will not pay for items or services provided by an excluded party, and providers that employ or contract with them risk the imposition of civil money penalties and significant overpayment liability. The focus of this article is to help providers understand their obligations with respect to exclusions, the risks they face if they fail to meet them, and how best to avoid those risks. I. What is an OIG Exclusion? OIG Exclusions are administrative sanctions that bar entities who present a risk to beneficiaries and health care programs from all participation in those programs. The Department of Health and Human Services (HHS), which is responsible for all Federal health care programs, delegated the authority to enforce federal exclusion regulations to its Office of Inspector General(HHS/OIG) and to maintain and update the “List of Excluded Entities and Individuals” (the “LEIE”). The use of exclusions as an enforcement tool to bar program participation by identified “bad actors” is not new. Congress initially authorized the exclusion of physicians under certain circumstances in Medicare and Medicaid Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977. The current framework of mandatory and permissive exclusions was then established by the Medicare and Medicaid Patient and Program Protection Act of 1987. II. Why are OIG Exclusions Imposed? There are two types of OIG Exclusions: Mandatory and Permissive. Mandatory Exclusions last a minimum of five years... --- - Published: 2023-10-01 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/screening-the-social-security-death-master-file/ - Categories: Medicaid Enforcement - Tags: Death Master File At Exclusion Screening, we often receive questions about the scope and frequency of an organization’s screening duties and responsibilities. One question in particular that we are regularly asked is whether an organization has an affirmative obligation to screen employees, agents, and contractors against the Social Security Administration’s Death Master File (Death Master File). As in the case of many Medicare and Medicaid regulatory obligations – it’s complicated. In this article, we examine the Death Master File and the role it plays in protecting the financial integrity of federal health benefit programs and the patients they serve. I. What is the Social Security Administration Death Master File? The Social Security Administration (SSA) master files contain, among other things, a registry of all Social Security beneficiaries (along with their assigned Social Security Numbers) issued by the government since 1936.   The Death Master File is a subset of the files contained in SSA’s “Numerical Identification System” or “Numident” database, which is itself a subset of the entire SSA master file collection. Numident contains the applications for social security numbers (the SS-5s) in addition to death and claim records, and the Death Master File is limited to the death records contained therein.   When an individual who qualifies for Social Security passes away, his or her death is generally reported to the Social Security Administration by either the decedent’s family, a funeral parlor or a government agency. The death record is then made a part of the Numident database and added to the... --- - Published: 2023-08-31 - Modified: 2025-08-25 - URL: https://exclusionscreening.com/resolving-exclusion-violations-through-the-oig-self-disclosure-protocol/ - Categories: Effect Of An Exclusion - Tags: Aca, Aca Related Permissive Exclusion Authorities, Authorities, Exclusion, Permissive I. Introduction The Office of Inspector General (OIG) has the authority to exclude providers from participating in federal health care programs and to impose civil money penalties (CMPs) for breaches of exclusion regulations. Since funds received by a provider in conflict with the payment prohibition that flows from an exclusion creates overpayment liability (regardless of intent or knowledge) and places the provider at risk for the imposition of CMPs, and since providers are obligated to investigate, assess and make full disclosure of potentially fraudulent conduct, providers must decide on how best to unwind exclusion violations. Toward that end, the OIG has issued the OIG Self-Disclosure Protocol which offers providers a concrete path to resolve these issues, and the focus of this article is to provide a detailed examination of the protocol and to assist providers who may be facing exclusion violations. II. Exclusion Violations: The 3-Headed Liability Monster:  Providers are always surprised that they hired or contracted with an excluded party and typically respond: “I had no idea they were excluded, and I certainly wouldn’t have employed or contracted with them if I had! ” Unfortunately, surprise turns to shock when they realize the scope and types of harm that have to be addressed to resolve the exclusion violation. Specifically, providers must resolve the following issues:  A. Overpayments Since Federal health care programs will not pay for any items or services furnished directly or indirectly by an excluded party, exclusion violations automatically generate overpayment which ultimately must be investigated, identified... --- - Published: 2022-03-02 - Modified: 2025-08-25 - URL: https://exclusionscreening.com/medicare-medicaid-providers-beware-nolo-contendere-plea-non-health-care-crime-can-still-result-exclusion-medicare/ - Categories: Effect Of An Exclusion - Tags: Action, Contendre, Exclusion, Nolo, Nolo Contendre Exclusion Action The last two years have been rough for everyone, and it has been particularly difficult for health care providers and suppliers. For example, the rapid spread of the Covid Omicron variant not only threatened to overwhelm a health care system that was already stretched to its limits, it also made it tougher than ever for Medicare and Medicaid providers to fill both skilled and non-skilled health care staff vacancies. Providers prone to high turnover, such as nursing homes, community care facilities, home health agencies and hospitals, were especially hard hit, but many health care employers had to dive deep into their applicant pools to identify and recruit qualified individuals and it is more important than ever that providers ensure that all new hires (along with their current staff members) have not been excluded from participation in any federal or state health benefit programs. I. Exclusion Basics: One of the most severe administrative sanctions available under the Social Security Act stems from the authority of the OIG to “exclude” individuals and entities from participating in federal health care programs. The purpose of an OIG exclusion action is to protect beneficiaries and safeguard the financial integrity of the Medicare Trust Fund, and the OIG can seek to exclude certain individuals and entities from participating in Federal health care programs under either mandatory and permissive exclusion authorities. Mandatory vs. Permissive Exclusion Actions. There are two types of OIG exclusions – “mandatory” and “permissive. ” Mandatory exclusions are administrative actions that are imposed for... --- - Published: 2021-11-02 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/cms-revocation-authority/ - Categories: Effect Of An Exclusion - Tags: Action, Exclusion, Exclusion Related Medicare Revocation Action, Medicare, Related, Revocation The Centers for Medicare and Medicaid Services (CMS) is the Federal agency tasked with the overall responsibility of managing the Medicare program. Thus, while the Office of Inspector General (OIG) is the primary agency responsible for protecting the integrity of the Medicare program, CMS and its various contractors serve as the program’s gatekeepers responsible for keeping problematic providers and suppliers from enrolling in the Medicare program in the first place or from remaining enrolled in the Medicare program if they pose a financial or safety risk to the program or its beneficiaries. I. Overview of CMS’s Existing Revocation Authorities: One of the principle tools used by CMS to protect the Medicare program from the participation of unscrupulous providers is its regulatory authority to revoke a provider’s Medicare billing privileges. In recent years, CMS’s regulatory authority to deny a provider’s enrollment OR to revoke a participating provider’s billing privileges has been greatly expanded. In addition to expanding the regulatory bases that CMS may rely upon when exercising its revocation authority, the 2019 Final Rule also extended the period that a revoked healthcare provider can be barred from reenrolling in the Medicare program from THREE YEARS to TEN YEARS. A summary overview of the current expanded list of reasons for revocation is discussed in an article entitled “Home Health Revocation Actions by Medicare are Expanding Around the Country. ” II. CMS Proposes to Expand its Revocation Authorities to Include the Exclusion of Virtually Anyone Associated with the Provided Earlier this year, CMS... --- - Published: 2021-10-25 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/expunged-conviction-extinguish-exclusion/ - Categories: Effect Of An Exclusion - Tags: Exclusion, Expungement, Impact, Impact Of Expungement On Exclusion Medicare and Medicaid providers / suppliers are prohibited from employing individuals who have been excluded from participation in Federal health care benefits programs. Similarly, participating providers and suppliers are also obligated to ensure that any business affiliates (such as vendors, contractors and agents) have not been excluded from participation. This article examines whether an individual convicted of a qualifying misdemeanor or felony who has been excluded is eligible to be hired if his or her felony conviction is later expunged from the criminal record. I. Exclusion Basics: The Department of Health and Human Services (HHS), Office of Inspector General (OIG) has been the proverbial “tip of the spear” with respect to protecting Medicare, Medicaid and more than 100 other programs from waste, fraud and abuse. During Fiscal Year 2020 alone, the OIG provided law enforcement oversight of more than $2. 2 trillion in spending by HHS. One of the primary ways that the OIG protects patients and safeguards the financial integrity of the Medicare and Medicaid programs is through the agency’s exclusion of certain individuals and entities from participation in Federal health care programs. II. Mandatory vs. Permissive Exclusion Actions: The OIG’s exclusion authority falls into two categories -- “Mandatory Exclusions” and “Permissive Exclusions. ” Mandatory Exclusions -- Mandatory exclusion actions are identified in Sections 42 U. S. C. §§ 1128(a)(1) – (4) of the Social Security Act (SSA).  If an individual or entity is convicted of certain program-related crimes, patient abuse, health care fraud or a controlled substance felony,... --- - Published: 2021-08-23 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/north-carolina-exclusion-screening-requirements/ - Categories: Medicaid Enforcement - Tags: Exclusions, Medicaid, North Carolina, North Carolina Medicaid Exclusions To understand the North Carolina Exclusion Screening Requirements, we must first touch upon Exclusions in general. Office of Inspector General (OIG) exclusions are one of the most powerful weapons available to the law enforcement in its efforts to fight healthcare fraud. Individuals and entities subject to an OIG exclusion are barred from participation in all Federal healthcare benefit programs, resulting in a payment prohibition on all items and services they provide, whether directly or indirectly. Additionally, providers that employ or contract with excluded individuals or entities risk the imposition of civil money penalties, overpayment liability, and even potential exposure under the False Claims Act. However, even though OIG exclusions are one of law enforcement’s oldest tools, many providers often fail to appreciate their compliance obligations and the risks associated with employing or contracting with excluded individuals or entities. Indeed, many providers take only minimal efforts to screen their employees and contractors to ensure compliance—and some make no effort at all. In addition to the Federal Exclusion List hosted by the OIG, individual states are allowed to create their own State Medicaid Exclusion Database. North Carolina is one of the 42 States (including the District of Columbia) that host their own list and therefore have their own Exclusion Screening Requirements. This article seeks to educate providers on the existing legal and regulatory framework, the risks and potential consequences of a failure to comply with those laws and regulations, and how best to comply and avoid those risks. We monitor all Federal... --- - Published: 2021-04-28 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/npdb/ - Categories: Exclusion Screening Basics - Tags: Npbd I. What is the NPDB The National Practitioner Data Bank (NPDB) was created as part of the Health Care Quality Improvement Act of 1986 (HCQIA). This legislation was intended, in part, to establish a database of medical malpractice payments, State licensure board actions, negative peer reviews / clinical privilege determinations, and certain other adverse actions taken against health care practitioners, providers, and suppliers. The NPDB currently contains more than 1. 6 million reports. In 2020, more than 65,000 new reports were submitted to the database. II. Who Has Access to the NPDB? The general public does not have access to provider-specific information stored in the NPDB. By law, access is restricted. The primary entities with access to the NPDB include: Hospitals and certain other health care entities (including professional societies). Quality Improvement Organizations (QIOs). State Licensing boards and certification authorities. Federal and State law enforcement agencies. Federal and state agencies administering or supervising the administration of government health care programs. Federal agencies responsible for the licensing and certification of health care practitioners, providers, and suppliers. Health plans. Health care practitioners, entities, providers, and suppliers requesting information reported to the NPDB concerning themselves (i. e. , only self-queries are permitted).   III. What are the Potential Penalties if an Entity Fails to Comply with the NPDB’s Reporting Requirements? The penalties and sanctions that may be assessed for failure to comply with the NPDB’s reporting requirements vary. For example: Malpractice payers (such as insurance companies) who fail to report medical malpractice payments... --- - Published: 2021-01-08 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/what-is-the-length-of-a-mandatory-exclusion/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Length, Mandatory, Mandatory Exclusion Length The Department of Health and Human Services (HHS), Office of Inspector General (OIG) is responsible for overseeing the financial and program integrity of more than 100 HHS programs, one of which is the Medicare program. As you would imagine, the Medicare program is quite costly. At the present time, it represents approximately 15% of the total annual Federal budget. When coupled with Medicaid and the Children’s Health Insurance Program (CHIP) costs, these health insurance programs collectively account for nearly 26% of the overall budget. One of the ways that the OIG protects these programs from waste, fraud and abuse is through the exercise of the agency’s exclusion authority. Depending on the facts of each case, the OIG may be mandatorily required to exclude certain individuals and entities from participating in Medicare and other Federal health benefit programs. In other cases, where mandatory exclusion is not required, the OIG may exercise permissive exclusion authority. This article focuses on the minimum length of a mandatory exclusion action and examines the extent which the OIG seeks to impose a period of exclusion longer than the minimum period proscribed by statute.   I. The Length of a Mandatory Exclusion Action Will be Not Less than Five Years: With limited exceptions, if an individual or entity is convicted of a criminal offense that meets the criteria set out in Section 1128(a) of the Social Security Act, the OIG is required by law to exclude the party for a period of not less than five years.... --- - Published: 2020-12-22 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/mandatory-exclusion-under-section-1128a4/ - Categories: Exclusion Screening Basics - Tags: Action, Controlled, Controlled Substance Conviction Exclusin Action, Conviction, Exclusion, Substance The Department of Health and Human Services (HHS), Office of Inspector General (OIG) exercises both mandatory and permissive exclusion authority with respect to Federal health care programs. In a recent New York case, the OIG was required by law to mandatorily exclude an individual for a minimum of five years due to her recent prosecution and guilty plea to a State felony in a controlled substances diversion case. While the facts in this case are relatively routine, there are a number of important points that are addressed in the petitioner’s appeal of the OIG exclusion action. This article examines those points. I. Background Facts: In this case, an individual working in a physician’s office surreptitiously obtained the physician’s prescription pad and fraudulently wrote out prescriptions. On at least 35 occasions, she took these prescription sheets to local pharmacies to obtain controlled substances that would have been otherwise unavailable to her without a proper prescription. After conducting an enforcement operation, State narcotics authorities charged the individual with felonious possession of controlled substances, forgery, and falsification of business records. The individual subsequently pleaded guilty to felony criminal possession of a controlled substance in the 4th degree under New York State Penal Code Section 220. 09(1), which mandates that: “ person is guilty of criminal possession of a controlled substance in the fourth degree when he knowingly and unlawfully possesses... one or more preparations, compounds, mixtures, or substances containing a narcotic drug and said preparations, compounds, mixtures, or substances are of an aggregate... --- - Published: 2020-11-23 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/collateral-consequences-state-medicaid-enrollment-termination-action/ - Categories: Medicaid Enforcement - Tags: Enrollment, Medicaid, Medicaid Enrollment Termination, Termination Exclusion Actions Under 42 U. S. C. § 1320a-7(b)(5)(B)  (November 2020): Since 1976, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) has been at the forefront of our nation’s efforts to fight waste, fraud and abuse in the Medicare, Medicaid and more than 100 other programs. Collectively, the costs of the federal programs safeguarded by the OIG exceed $1 trillion each year. One of the ways that the OIG protects both patients and the financial integrity of the Medicare and Medicaid programs is the agency’s exercise of its authority to exclude individuals and entities from participating in the Medicare,   and other federal health care programs.  This article reviews a recent case where an individual working as a in-home personal care worker providing services to a disabled client was alleged to have engaged in improper billing practices. Ultimately, the domino-effect of this these allegations led to imposition of significant and severe administrative sanctions, culminating in the individual’s exclusion from participation in the Medicare and Medicaid programs under 42 U. S. C. §1320a-7(b)(5)(B). I. Improper Conduct Committed While Serving as a Homecare Worker Can Lead an Individual’s Enrollment in the State Medicaid Program: In a recent case out of Oregon, the Oregon Department of Human Services, Aging, and People with Disabilities (ODHS) terminated the enrollment of a homecare worker in the state’s “Consumer-Employed Provider Program,” which provides Medicaid in-home services, such as help with a client’s activities of daily living (ADLs), to qualified disabled persons. ODHS’s... --- - Published: 2020-07-01 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/which-exclusion-lists-should-be-screened-2/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Exclusion Lists, Lists The complex web of regulation encompassing government health care dollars is a lot to take on. With 41 state exclusion lists and several federal lists, it can be difficult to know which exclusion lists to screen, let alone actually screen them all. Each government payor of healthcare dollars has a different set of rules on who is allowed and who isn’t allowed to bill their services. Healthcare providers are not legal experts, nor should they have to be. Rather than taking the risk of non-compliance, we break down exclusion regulations for you and explain which exclusion, sanction, debarment, or termination list you must check as a healthcare provider. I. What is an Exclusion? Exclusions are a final administrative action that is intended to protect the financial integrity of health benefit programs and beneficiaries by removing individuals and entities that pose a risk to them. While a party does have the right when noticed that they are about to be excluded, as a final administrative action, once excluded there is no further appeals process. II. Impact of Exclusions An exclusion is the nuclear bomb of administrative actions. As a result of an exclusion, a payment prohibition is enforced. Federal and State programs will not pay or items or services furnished, directly or indirectly, by excluded entities. In essence, the government has decided that they do not want programs to pay for the overhead or salaries of excluded parties. Therefore, to comply with exclusion regulations it is best to screen all employees,... --- - Published: 2020-04-01 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/mandatory-exclusion-state-convitions/ - Categories: Effect Of An Exclusion - Tags: Abuse, Exclusion, Exclusion Related To Patient Abuse, Patient, Related, To The Department of Health and Human Services (HHS), Office of Inspector General (OIG) may be required by law under Section 1128 of the Social Security Act to exclude individuals and entities from participating in Federal health care benefits programs if an individual or entity has been convicted of certain crimes or has engaged in certain conduct. Depending on the nature of an adverse action, the OIG’s statutory obligation may be to impose a mandatory exclusion or permissive. This article examines the impact of a State-based conviction for patient neglect or abuse and discusses the OIG’s obligations to exclude an individual when faced with these facts. I. Case Background: On January 31, 2017, a New York Licensed Practical Nurse (LPN) pleaded guilty to violating New York Public Health Law §§ 12-b(2) and 2803-d(7), both of which were misdemeanors, as well as to disorderly conduct. By pleading guilty, LPN admitted that they, “willfully violated a provision of the Public Health Law by subjecting ... to an act of negligent by failing to provide that person with timely, consistent, safe, adequate and appropriate services, treatment and care. ” Under the plea agreement, if the defendant completed a 12-week elder abuse program and agreed not to provide health care to elderly persons for a period of a year she would be eligible to receive a, “conditional discharge on a violation ... ith a $250 fine. ” On January 31, 2018, the New York Supreme Court held a sentencing hearing and found that the defendant... --- - Published: 2020-03-30 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/confirmed-exclusion-options/ - Categories: Effect Of An Exclusion - Tags: Employee, Excluded, Excluded Employee After finding a confirmed exclusion among your employees, vendors, contractors, or volunteers there are several options you can take. Each case with a confirmed exclusion is fact-specific, there is no “rubber-stamp” approach to this problem. This article discusses and outlines possible paths that can be taken by entities after finding a confirmed exclusion.   I. Review of Exclusions “Exclusions” are final administrative actions by State or Federal agencies that bar participation in a sponsored benefit program. An agency has the power to exclude parties within the area they control. The OIG excludes parties from Medicare, while states can exclude parties from their State Medicaid Program. Exclusions occur when the party poses an unacceptable risk to the integrity of the program and to the beneficiaries the program serves. They often happen after patient abuse, fraud, drug convictions, or licensure issues, among other offenses. Confirmed exclusions not only pose a risk to program integrity but to your organization as well. Working with an excluded party, either directly or indirectly, risks overpayments, civil money penalties, and false claim act violations. These parties are also a direct risk to your organization. They have done some wrong in the past, who is to say they will not happen while in your organization?   Screening for exclusions is not just for ‘checking the box’. You do not do it simply because you have to, but rather it is important to do to protect your organization. It is often difficult for providers to understand what exclusion screening... --- - Published: 2020-01-16 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/massachusetts-medicaid-exclusion/ - Categories: Medicaid Enforcement - Tags: Exclusions, Massachusetts, Massachusetts Exclusions Massachusetts Medicaid Exclusion Screening: Requirements and Best Practices for Compliance The Massachusetts Medicaid Exclusion requirements, under MassHealth, will not reimburse any item or service furnished directly or indirectly by individuals or entities that have been excluded from any State or Federal health care programs. This broad “Payment Prohibition” is enforced by the Massachusetts Executive Office of Health and Human Services, Office of Investigation General (MA-IOG) through rigorous exclusion screening requirements and the threat of civil money penalties and overpayment liability. This article discusses the exclusion screening obligations that providers of Medicaid services in Massachusetts must comply with, and it suggests best practices to promote compliance. What is a Medicaid Exclusion? “Exclusions” are final administrative actions by State or Federal agencies that bars all participation in a sponsored benefit program. When a State bars and individual or entity from participating in its Medicaid program, that is typically referred to as a “Medicaid Exclusion;” similarly, when someone is barred from the Medicare program, that is commonly referred to as a “Medicare Exclusion. ” Massachusetts is one of the 41 States that maintains its own exclusion list (DC also has one), and it can be found on the MassHealth website at https://www. mass. gov/service-details/learn-about-suspended-or-excluded-masshealth-providers. The OIG’s “List of Excluded Individuals and Entities” (LEIE) contains the federal Medicare Exclusions, and it is maintained on the OIG website at https://exclusions. oig. hhs. gov/. States without their own exclusion lists rely on the LEIE. Who Gets Excluded? Why are Exclusions Imposed? The primary reasons for MassHealth... --- - Published: 2019-10-09 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/hiring-federally-excluded-individuals/ - Categories: Effect Of An Exclusion - Tags: Contracting, Contracting With Excluded Entity, Entity, Excluded Should you choose to participate in the Medicare and/or Medicaid programs, you must comply with a wide variety of program integrity requirements. One obligation, in particular, is often missed by physician practices, home health agencies, hospices, and laboratories – the “screening” of employees, contractors, and agents to ensure that the provider or supplier has not employed or entered into a business relationship with an individual or entity that has been excluded from participation in Federal health care programs. Does that mean that a Medicare provider can never employ an excluded individual or entity? Such as someone on the Medicare Exclusion List? Not necessarily. In this article, we will examine how the Department of Health & Human Services (HHS), Office of Inspector General (OIG) has interpreted the impact and scope of an exclusion action. I. How Did Medicare Exclusion List Screening Obligations Arise? When reviewing mandatory exclusion screening obligations with health care providers and suppliers, we are regularly asked – How did this obligation arise? As described below, as a participating provider in the Medicare and / or Medicaid program, you have been prohibited from employing (or contracting with) any individual or entity that has been excluded from participation in Federal health benefit programs for more than 40 years. A brief overview of the evolution of your statutory and regulatory exclusion screening obligation is set out below: Medicare-Medicaid Anti-Fraud and Abuse Amendments. The statutory basis for the mandatory exclusion (from Medicare, Medicaid and other Federal health care programs) of physicians and... --- - Published: 2019-09-26 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/pennsylvania-doctor-excluded/ - Categories: Medicaid Enforcement - Tags: Care, Quality, Quality Of Care Over the past year, both State and Federal law enforcement investigators and prosecutors have gone to considerable lengths to publicize the government’s fight against opioid abuse. While much of this fight has focused on the manufacturers of prescription opioid products, the improper prescribing practices of physicians and other medical professionals found to be prescribing these drugs “without any legitimate purpose and outside the usual course of professional practice” have been repeatedly highlighted in criminal prosecutions by U. S. Attorney’s Offices around the country. A recent case against a Philadelphia-area cardiologist provides a classic example of how improper opioid prescribing practices can lead to criminal prosecution, civil penalties AND severe administrative sanctions (in this case, exclusion from participation in Federal health care programs). The article examines how the cardiologists was identified and steps you should take to reduce your level of risk in this regard. I. Background of the Case: Like many big cities, Philadelphia has a problem with illegal drugs. Despite the city’s efforts to curb illicit drug use, unintentional drug overdoses have steadily grown since 2010 and have only slightly tapered-off from their all-time high since 2017. We monitor all Federal & State Exclusion Lists Exclusion Screening, LLC is proud to offer those interested in trying our product and service a no cost, no obligation TRIAL Period. Our trial is multi-faceted and is aimed to expose the client to as much of our service and product as possible in a short time. The trial starts with a FREE consultation/training... --- - Published: 2019-06-10 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-semi-annual-report-congress-fall-2018-spring-2019/ - Categories: Medicare Enforcement - Tags: Fy2019, Fy2019 Oig Semi Annual Report, Oig, Report, Semi Annual The Office of Inspector General (OIG) recently published its Semi-Annual Report to Congress covering from October 1, 2018 to March 31, 2019. The OIG report focuses on the enforcement actions that were brought and the exclusions that were imposed during the past reporting period in support of the agency’s mission to protect patient safety and the financial integrity of federally funded healthcare programs. Since 2004, the OIG has recovered over $53 billionand Excluded 50,877 Individuals and Entities from participating as enrolled providers in Federal healthcare programs. It has also filed over 11,000 criminal actions against those who were alleged to have committed crimes against its healthcare programs and filed over 7,000 civil actions seeking civil monetary penalties and administrative recoveries in “False claims and unjust-enrichment lawsuits filed in Federal district court. I. Highlights of OIG Actions During the last reporting period of the OIG issued 71 audits and 10 evaluations in which the OIG issued 212 recommendations to HHS operating divisions. The OIG also identified just short of $500 million in expected recoveries. In addition, OIG identified over $245 million in “questionable costs” from alleged violations, inadequate documentation, or unreasonable spenditures. As a result of its actions during the reporting period, the OIG expects to recover $2. 3 billion in addition to pursuing 391 criminal healthcare fraud matters and initiating 327 civil actions against individuals or entities that also engaged in offenses related to healthcare fraud and risked the financial integrity of its healthcare programs. In April, 2019, the OIG announced,... --- - Published: 2019-05-03 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/alabama-exclusion-screening-requirements/ - Categories: Medicaid Enforcement - Tags: Alabama, Alabama Exclusions, Exclusions (May 2, 2019) The Alabama Medicaid Program imposes significant exclusion screening requirements on its providers. Many are unaware of the extent of their exclusion screening obligations or of the severe consequences that can result from a failure to properly screen. This short summary has been prepared to help further provider awareness of the exclusion screening rules and regulations in force and the effect of an Alabama exclusion. I. Basic Alabama Exclusion Screening Requirements Providers must screen all employees and contractors by searching the Alabama Medicaid Exclusion List, the HHS-OIG List of Excluded Individuals or Entities (LEIE), and the GSA/SAM (System for Award Management) website prior to hiring and monthly there after to ensure that none have been excluded from participation in the program since the last search. (Alabama Medicaid Provider Manual, 7. 3. 1, January, 2019. ) II. Additional Alabama Exclusion Screening Requirements Arising from Provider Enrollment Provider must identify all owners, officers, shareholders of greater than 5%, agents, directors and managing employees and, for each, disclose whether than have ever been excluded, debarred, or sanctioned from any state or federal program. (Alabama Provider Disclosure Form, amended July 2018. ) III. Excluded Parties are Banned From All Participation in Alabama Medicaid Excluded entities are banned from participating in Medicaid and the program will not pay for any item or service furnished by or at the medical direction of an excluded party. The payment prohibition extends to services that are not directly billable such as nursing care in ahospital or nursing home; indirect services that... --- - Published: 2019-04-08 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/internal-compliance-whistleblowing-system/ - Categories: Compliance Hotlines - Tags: Compliance, Compliance Hotline System, Hotline, System (April 4, 2019): In December of 2018 a study was conducted by Kyle Wench (George Washington University) and Stephen Stubben (University of Utah) to examine the use and extent of internal whistleblower hotline systems within publicly traded organizations. This study was the first of its kind. This kind of study had never before been conducted in the academic field. Their goal was to “... provide the first empirical examination in the academic literature of the determinants of outcomes associated with the use of internal whistleblowing systems”. While all publicly traded companies are required by the 2002 Sarbanes-Oxley Act to employ an internal reporting system (such as a “Compliance Hotline”), whether this internal whistleblower hotline is really used or just there to fulfill the requirement was not fully known prior to this study. I. Overview of this Landmark Hotline Study: Wench and Stubben’s study was conducted by examining proprietary data derived from over 1. 2 million internal whistleblower hotline reports filed within over 900 publicly traded firms inside the U. S. to “provide the first empirical examination in the academic literature of the determinants of and outcomes associated with the use of internal whistleblower hotline systems. ” This study led them to want to answer two main questions. The first being, what firms are likely to actively use and internal whistleblower hotline system. The second being what the correlation was between the use of an internal whistleblower hotline and concomitant litigation. This study used information and reports from a third-party internal... --- - Published: 2019-04-02 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-enforcement-actions-notable-decisions-from-march-2019/ - Categories: Medicare Enforcement - Tags: Action, Exclusion, Facility, Nursing, Skilled, Skilled Nursing Facility Exclusion Action (April 2, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), has continued its goal of enforcing its guidelines and rules upon medical providers participating in their programs. The OIG has kept pursuing its goal of protecting the integrity of its federal health care programs and their respective patients. Several notable cases in which the OIG found inaccuracies or fraud are highlighted below: (March 1, 2019). A Skilled Nursing Facility located in Tennessee Settled a Case Involving Excluded Individual On March 1, 2019, a Health Care Center located in Jackson, Tennessee, was forced to enter into a $81,419. 42 settlement agreement with OIG. This pricey agreement resolved any accusations that the Skilled Nursing facility had hired an individual who was on the exclusions list meaning they are excluded from participating in any Federal health care program. The OIG investigation revealed that the excluded individual, a registered nurse, provided items or services to the facilities patients that were billed to Federal health care programs. (March 8, 2019). Oklahoma Skilled Nursing Facility Settles Case Involving Excluded Individual On March 8, 2019, a Nursing and Rehabilitation facility located in Cleveland, Oklahoma, was forced to enter into a $171,047 settlement agreement with OIG. The settlement agreement put to rest allegations that the Skilled Nursing facility employed an excluded individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, an office manager, provided items or services to patients that were billed... --- - Published: 2019-03-01 - Modified: 2025-08-25 - URL: https://exclusionscreening.com/february-recap-oig-enforcement-actions-notable-decisions/ - Categories: Medicare Enforcement - Tags: Action, Counselor, Exclusion, Health, Mental, Mental Health Counselor Exclusion Action (March 1, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), has continued its goal of enforcing its guidelines and rules upon medical providers participating in their programs. The OIG has kept pursuing its goal of protecting the integrity of its federal health care programs and their respective patients. Several notable cases in which the OIG found inaccuracies or fraud are highlighted below: (February 6, 2019). Ohio Practice and Owner Settle Case Dealing with False Claims On February 6, 2019, A doctor owned practice was forced to face allegations that they had submitted claims to Medicare for specimen validity testing (SVT), a non-covered service. SVT is a quality control process that evaluates a urine drug screen sample to determine if it is consistent with normal human urine and to ensure that the sample has not been substituted, adulterated, or diluted. To settle these allegations, the practice was forced to pay $111,706 to OIG. (February 7, 2019). A Tennessee Based Prosthetics Company Settled a Case with OIG Over Allegations of Kick-Backs On February 7, 2019, a prosthetics company out of Nashville, Tennessee, entered into a $681,774 settlement agreement with OIG. The settlement agreement put to rest allegations that that the organization had offered and paid illegal remuneration to two surgical practices and a prosthetist in the form of fee reductions and payments. OIG alleged that the organization cuts its monthly rate for a surgical practice based in Texas in an amount that was equal to the... --- - Published: 2019-02-13 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/cms-preclusion-list/ - Categories: Preclusion List Screening - Tags: Cms, Cms Preclusion List, List, Preclusion Beginning April 1, 2019, the new CMS Preclusion List will go into effect subsequently barring many healthcare professionals from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. But what is the Preclusion List? Who is on it? Why was created? Don’t worry, we’re going to break down everything you need to know about this new CMS action and how it can affect your organization. I. What is the CMS Preclusion List? The Preclusion List is a list generated by CMS that contains the names of prescribers, individuals, and or entities that are unable to receive payment for Medicare Advantage (MA) items and service and or Part D drugs prescribed or provided to Medicare beneficiaries. II. How Does Someone End up on The CMS Preclusion List? CMS has given two ways for which someone can end up on the Preclusion List. The first one way is if you: “Are currently revoked from Medicare, are under an active re-enrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program” However, even if you are not revoked from Medicare, you still may find yourself on the Preclusion List. CMS is also precluding anyone who has: “... Engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct... --- - Published: 2019-02-07 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/review-oig-in-fiscal-year-2018/ - Categories: Medicare Enforcement - Tags: Actions, Exclusion, Fy2018, Fy2018 Oig Exclusion Actions, Oig By Cason Liles (February 6, 2019): The Department of Health and Human Services (HHS), Office of Inspector General (OIG) is an independent, objective law enforcement and investigative agency that is responsible for protecting the financial integrity of the more than 300 programs that are administered by HHS. Collectively, these programs represent approximately 24% of the Federal budget. Although OIG is responsible for investigating allegations of fraud, waste and abuse related to literally hundreds of HHS programs, most of OIG’s investigative and enforcement activities arise out the Medicare and Medicaid programs. Simply put, OIG’s mission is fighting fraud, waste and abuse. In the pursuit of this mission, OIG aggressively investigates allegations of wrongdoing to identify and recover improper payments made to health care providers, suppliers and other parties who have engaged in fraudulent, wasteful or abusive conduct. One of the key tools used by OIG to protect patients and safeguard the financial integrity of the Medicare and Medicaid programs is its authority to exclude individuals and entities from participation in Medicare, Medicare and other Federal health care benefit programs. This article examines a number of the exclusion-related enforcement actions taken by the OIG in Fiscal Year (FY) 2018. I. An Overview of FY 2018 Exclusion Actions: At the outset, it is important to keep in mind that “exclusion” actions aren’t new. They were first mandated in 1977 as part of the “Medicare-Medicaid Anti-Fraud and Abuse Amendments,” Public Law 95-142. The responsibility for imposing mandatory and permissive exclusion actions rests with OIG. As in... --- - Published: 2019-02-06 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-enforcement-actions-notable-decisions-january-2019/ - Categories: Medicare Enforcement - Tags: Action, Assisted, Assisted Living Facility Exclusion Action, Exclusion, Facility, Living (February 6, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), didn’t skip a beat ringing in the new year. The OIG kept pursuing its goal of protecting the integrity of its federal health care programs and their respective patients. Several notable cases in which the OIG found inaccuracies or fraud are highlighted below: (January 4, 2019).  Oklahoma Assisted Living Facility Settles Case Involving an Excluded Individual. An assisted living facility (ALF) in Owasso, Oklahoma agreed to pay the OIG more than $96,000. This action was taken due to the fact that the ALF improperly hired and excluded individual. Notably, the excluded individual was an “Admissions Specialist,” not a direct caregiver (such as a physician, nurse, medical assistant, etc. ). This case aptly illustrates the importance of screening ALL employees, contractors, agents and vendors. As the OIG has previously noted, even volunteers must be screened.   (January 4, 2019). The State of Rhode Island Did Not Ensure Its Managed Care Organizations Complied with Requirements Prohibiting Medicaid Payments for Services Related to Provider-Preventable Conditions Upon investigation, the OIG found that Rhode Island was not meeting certain requirements that had been set forth by the Federal and State government. Specifically, Rhode Island was not ensuring that its Medicaid managed-care organizations (MCO) prohibited Medicaid payments to providers for inpatient hospital services related to treating certain provider-preventable conditions (PPCs). For the audit period, OIG concluded that Rhode Island’s managed care organizations had paid providers around $4 million for almost 250... --- - Published: 2018-12-17 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/texas-medicaid-exclusions/ - Categories: Providers Guides - Tags: Exclusions, Texas, Texas Exclusions (December 17, 2018): Texas Medicaid Exclusions will prevent the Texas Medicaid Program from paying for any item or service furnished directly or indirectly by individuals or entities that have been excluded from a State or Federal health care program. This results in a broad “Payment Prohibition” that is enforced by the Texas Health and Human Services Commission, Office of Inspector General (HHSC-OIG) through a comprehensive regulatory scheme that includes the imposition of strict provider exclusion screening requirements. This article will discuss how providers are impacted by these regulations and the exclusion screening obligations they impose; the risks of compliance failures; and it will suggest best practices to help providers to help providers comply with their obligations and avoid those risks.   I. What is a Texas Medicaid Exclusion? “Exclusions” are final administrative action by a State or Federal agency that bars an individual or entity from participating in one of its benefit programs. When a State forecloses participation in its Medicaid programs, that action is often referred to as a “Medicaid Exclusion. ” Similarly, when the Department of Health and Human Services (HHS), Office of Inspector General (OIG) bars participation in Medicare program, that is commonly referred to as a “Medicare Exclusion. ” Texas Medicaid Exclusions are posted on database maintained on the Texas HHSC-OIG website, and Medicare Exclusions are posted on the OIG’s “List of Excluded Individuals and Entities” (LEIE) which is maintained on its website. II. Who Gets Excluded? Why are Texas Medicaid Exclusions Imposed? Texas Medicaid Exclusions... --- - Published: 2018-08-30 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-exclusion-case-study-impact-false-claims-act-judgment/ - Categories: Medicare Enforcement - Tags: Act, Based, Exclusion, Exclusion Based On False Claims Act Judgment, False, Judgment (August 23, 2018): In 2008, after learning that a Texas-based laboratory services company was submitting false claims to the Medicare program, a private citizen filed suit, on behalf of the United States, against the laboratory services company under the qui tam provisions of the civil False Claims Act. The qui tam provisions of the False Claims Act (31 U. S. C. §§ 3729 – 3733) allow private parties, commonly referred to as “whistleblowers” or “relators” to sue individuals and entities on behalf of the government if the defendants have “knowingly” submitted false claims to the government for payment. In this case, the United States intervened in the case against the laboratory services company in 2011. In April 2018, the U. S. District Judge hearing the case ruled against the laboratory and its physician owner and awarded the United States $30. 5 million for violations of the False Claims Act. Although there are a number of lessons (especially with respect to individual liability) to be learned from the underlying case, the purpose of this article to examine the collateral administrative actions that were taken against the physician owner and the laboratory services company. I. Parallel Administrative Action -- OIG Exclusion Action Overview:  In a letter dated August 21, 2015, the Department of Health and Human Services, Office of Inspector General (OIG) proposed to exclude the laboratory services company, and its owner, from participation in Medicare, Medicaid, and other Federal health programs under 1128(b)(7) of the Social Security Act, for a period... --- - Published: 2018-07-30 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/licensure-action-oig-exclusion/ - Categories: Effect Of An Exclusion - Tags: Criminal Plea, Exclusion, Impact, Impact Of Criminal Plea On Exclusion Perhaps the most severe administrative sanction available under the Social Security Act stems from the authority of the Secretary for the Department of Health and Human Services (HHS) to exclude individuals and entities from participating in Federal and State health benefits programs. The Secretary has delegated this authority to the HHS, Office of Inspector General (OIG). As a recent comprehensive, first-of-its-kind study by ExclusionScreening. com found that during the period 2013 to 2017, approximately 90% of the permissive OIG exclusion actions taken were based on an adverse administrative action taken against a healthcare provider’s license. This article examines a decision issued earlier this year by the HHS Departmental Appeals Board (DAB or Board) where the Board examined a licensure-related exclusion action in considerable detail. I. Brief Overview of OIG Licensure-Related Exclusion Action:  With the passage of the Medicare-Medicaid Anti-Fraud and Abuse Amendments in 1977, mandatory OIG exclusion became mandated in cases where a physician and other practitioner has been convicted of program-related crimes. (now codified at section 1128 of the Social Security Act). Since that time, various additional bases for both mandatory and permissive exclusion have been enacted.  Collectively assessed, the most frequent statutory basis relied on by the OIG when seeking to exclude an individual from participation in Federal and State health care programs is “42 USC §1320a-7(b)(4) License Revocation or Suspension. ” As this provision set out:“Any individual or entity—(A) whose license to provide health care has been revoked or suspended by any State licensing authority, or who... --- - Published: 2018-01-22 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/personal-care-service-aides-attendants-excluded-2017/ - Categories: Medicaid Enforcement - Tags: Aides, Care, Exclusion, Exclusion Of Personal Care Aides, Personal (January 22, 2018): With 2017 behind us, it can be quite helpful to review the Medicare “exclusion” actions taken by the Department of Health and Human Services, Office of Inspector General (HHS-OIG) to gauge the level of regulatory exclusion risk presented by aides and attendants working for personal care agencies around the country. As a review of these actions will show, personal care services aides and attendants were among the most frequent type of health care provider excluded from participating in Federal health care benefits program by HHS-OIG during calendar year 2017.   It is therefore essential that owners of personal care agencies take affirmative steps to ensure that they have robust, effective systems in prevent excluded individuals from being hired or otherwise engaged to care for Medicaid beneficiaries. To accomplish this, agencies must screen their employees, vendors or contractors against all Federal and State exclusion lists every 30 days. An overview of the 2017 exclusion actions taken against personal care aides and attendants is set out below. I. What is an “Exclusion” Action? The “exclusion” of individuals or entities from participation in Federally-funded programs is covered under § 1128 of the Social Security Act. When an individual or entity is excluded from participation, the excluded party is essentially barred from Federal health benefits programs. This makes them untouchable by almost any healthcare related entity. With the exception of losing one’s professional license (for instance, if you are a licensed physician, nurse or pharmacist), being excluded is the most severe administrative... --- - Published: 2018-01-12 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/dental-oig-exclusion-actions/ - Categories: Medicare Enforcement - Tags: Actions, Dentist, Dentist Exclusion Actions, Exclusion (January 12, 2018): The Medicare and Medicaid programs are both essential, yet costly health benefit programs sponsored in whole or in part by the Federal government. With Medicare and Medicaid costing $686 and $368 billion each year, respectively, the government has dedicated experienced investigators, auditors and prosecutors to ferret out incidents of health care fraud and abuse. While most health care fraud administrative, civil and / or criminal cases are brought against medical providers, dental providers and the members of their staff are increasingly finding that their actions are under scrutiny by Federal and State regulators. A prime example is illustrated by the various “dental OIG exclusion” actions taken against dentists and dentist office staff last year during 2017.   I. What is an “Exclusion” Action? Simply put, under certain circumstances, the Department of Health and Human Services, Office of Inspector General, Office of Inspector General (HHS-OIG) is mandated by law to “exclude” individuals and entities from participating in Federally funded health care program under 1128 of the Social Security Act (SSA), and from Medicare and State health care programs under section 1156 of the SSA. Under other circumstances, HHS-OIG exercises the discretionary authority to decide whether or not to exclude a party. During 2017, HHS-OIG took a number of administrative exclusions actions against dentists and dental practice personnel in order to meet their statutory obligations. As set out below, a brief description of the exclusion actions taken against dental professionals, along the frequency of their occurrence are described in the... --- - Published: 2018-01-08 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/medicare-revocation-and-exclusion/ - Categories: Effect Of An Exclusion - Tags: Discipline, Reciprocal, Reciprocal Discipline (January 8, 2018): Most physicians will progress through their entire career without ever having to respond to a complaint or investigation by their State Medical Board. Unfortunately, that isn’t always the case. An average of 4,309 physicians are disciplined each year by state licensure boards around the country. A recent case aptly illustrates how a state licensure action that merely resulted in probation ultimately led to the revocation of a physician’s Medicare billing privileges. I. Background Facts: Dr. Smith (not his real name), was a Board Certified Family Medicine physician who was first licensed to practice medicine in Tennessee in August 2006. He subsequently joined a cosmetic practice in 2007 and performed liposuction procedures. Although it is unclear how the matter came to the Tennessee Board’s attention, the Board alleged that Dr. Smith violated the Tennessee Medical Practice Act when he incorrectly used the tumescent liposuction procedure and removed an amount of fat from patients that exceeded the limit allowed for both Level I and Level II office-based surgery. A. Disciplinary Action Taken by the Tennessee Board of Medical Examiners. In late 2012, the Tennessee Board reached a settlement with Dr. Smith with respect to his liposuction practices. The terms of the agreement were that Dr. Smith agreed to be on probation for not less than five years, to pay a civil penalty, and to certain restrictions on his performance of cosmetic procedures. Notably, there were no allegations in the Consent Order that suggest that patients were injured by Dr.... --- - Published: 2017-12-22 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-podcast/ - Categories: Medicare Enforcement - Tags: 2017, 2017 Exclusion, Exclusion Year in Review OIG Podcast Earlier this week, the Office of Inspector General released its “Year in Review” OIG Podcast highlighting the OIG’s major accomplishments for 2017. The OIG podcast reported 881 criminal actions, 826 civil actions and over $4 billion in recoveries. OIG also excluded 3,244 from participating in federal health care programs during the year. Interestingly, the podcast cites the $155 million False Claims Act settlement with an electronic health records vendor as one of the year’s major accomplishments. The investigation focused on misrepresentations made by the defendant regarding the capabilities of the company’s software, and the settlement was reported to be the first of its kind with an electronic records vendor. As stated in a prior OIG podcast, “accurate medical records, including electronic health records, or EHR, are the foundation of providing quality healthcare to patients. ” The July takedown in which 412 defendants were charged with $1. 3 billion in false billings to Medicare and Medicaid was the next accomplishment cited in the podcast. The massive, coordinated takedown involved 350 agents in 41 judicial districts, and charges were brought against 115 doctors, nurses and other licensed professional. The takedown also included opioid - related charges against 120 individuals, and 295 exclusion notices related to the use and abuse of controlled substances were issued. On the day of the takedown, the OIG released a data and information on its concerns about questionable prescribing and extreme use of opioids. Click here to listen to the remarks of IG... --- - Published: 2017-08-16 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/pain-management-prescribing-practices/ - Categories: Medicare Enforcement - Tags: Management, Pain, Pain Management Prosecutions, Prosecutions (August 16, 2017): Earlier this summer, the U. S. Department of Justice (DOJ) executed its most extensive “health care fraud takedown” to date, initially arresting 412 licensed healthcare providers, doctors, and nurses alleged to have engaged in fraudulent conduct. As Attorney General Jeff Sessions stated at that time, “We are sending a clear message to criminals across this country: We will find you. We will bring you to justice. And you will pay a very high price for what you have done. ” Of the 412 individuals arrested, approximately 120 of the defendants, including doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics. The charges aggressively targeted pain management providers billing Medicare, Medicaid, and TRICARE for medically unnecessary prescription drugs and compounded medications that often were never even purchased and / or distributed to beneficiaries. Many of the charges brought against pain management professionals have alleged that these individuals have contributed to the nation’s current opioid epidemic through the unlawful distribution of opioids and other prescription narcotics. I. Pain Management Providers Around the Country are Being Targeted by DOJ: To be clear, there is, in fact, a significant problem with prescription opioid abuse and diversion. In the first six months of 2017, there have been a number of federal enforcement cases brought against pain management physicians, practices and clinics for a wide variety of opioid-related violations. Several of these include: February 2017: In this Pennsylvania case, a pain management physician pleaded guilty to selling... --- - Published: 2017-06-08 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/significant-recent-trends-exclusion-case-settlements/ - Categories: Medicare Enforcement - Tags: Action, Center, Exclusion, Rehabilitation, Rehabilitation Center Exclusion Action The Office of the Inspector General (OIG) has recently entered into a number of exclusion case settlements tied to skilled nursing facilities and hospitals. Additionally, there have been several recent investigations targeted towards physician practices. A rising number of these cases with sizable settlement recoveries highlight an emerging trend to be on the lookout for. I. Recent Exclusion Case Settlements There appears to be a growing number of skilled nursing facilities and hospitals being implicated in connection with employing excluded individuals. In November 2016, a New York rehabilitation center entered into a $205,089 settlement agreement with OIG. It was alleged that the facility employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual was a licensed practical nurse, who provided items or services to the center’s patients that were billed to Federal health care programs. Similarly in the same month, another New York rehabilitation center entered into a $110,223 settlement agreement with OIG. The investigation revealed that one excluded individual was a registered nurse supervisor and another was a licensed practical nurse, both having provided items or services to the facility’s patients that were billed to Federal health care programs. Also in November 2016, a California hospital agreed to pay $190,087 for allegedly violating the Civil Monetary Penalties Law following a Self-Disclosure Protocol (SDP) settlement. In July 2016, a North Carolina and a California hospital agreed to pay $475,220 and $207,698 respectively for allegedly violating the Civil Monetary Penalties Law. In each of... --- - Published: 2017-05-26 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/home-health-final-rule-exclusion/ - Categories: Medicare Enforcement - Tags: Care, Fraud, Health, Health Care Fraud Exclusion News (May 22, 2017):Health Care Fraud will continue to be a high priority of the Department of Justice Kenneth Blanco, the Acting Head of the Criminal Division. Describing health care fraud as “egregious,” “despicable” and driven by “greed” – Mr. Blanco, told the iABA Health Care Fraud Institute last week. went on to say that the department would be “vigorous” in its pursuit of those who violate the law in this area. ” Department of Justice announcements of its commitment to health care fraud enforcement are common and would hardly have been noticed in prior administrations. But by going out of his way to “be clear” that health care fraud is “something that Attorney General Sessions feels very strongly about” and remains a “priority” for DOJ, Mr. Blanco appears to be sending the message that health care fraud had not been left behind in a Justice Department that has been pursuing several new initiatives and has several new areas of focus.   A Concern that Health Care Fraud Deprives Care to the those in Need While patient safety and financial costs have been the longstanding focus of health care fraud enforcement, Mr. Blanco told the conference attendees that money stolen is “important,” but that his focus was on the impact that health care fraud has by denying services to those in need. In his view, health care fraud “deprives many people of access to medical care, even the most basic forms of care, because fraud increases the costs for all of us... --- - Published: 2017-05-03 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-screening-compliance-role/ - Categories: Effect Of An Exclusion - Tags: Guide, Hcca, Hcca Resource Guide, Resource The recently issued Resource Guide for Measuring Compliance Program Effectiveness, reconfigures the traditional formulation of the “Seven Elements of an Effective Compliance Program by making the “Screening and Evaluation of Employees, Physicians, Vendors and other Agents” an element unto itself – or the new “Seventh Element of Compliance! ” The Resource Guide, a product of roundtable discussions by staff members of the Office of Inspector General and compliance professionals and prepared under the auspices of the Health Care Compliance Association (HCCA), serves to once again underscore the critical role of exclusion screening and background checks in compliance The Importance of the Hiring Process in Health Care Employee suitability is critically important in healthcare because most of a provider’s operational costs, and almost all of his risks, are directly related to his employees. Whereas most industries are trying to respond to a wide range of risks over which they have little or no forewarning or control (for example, the impact of weather, the availability of supplies or critical equipment, or the failure of equipment they neither own or operate), the majority of risks to health care providers are mostly known and directly related to employee conduct or misconduct (medical malpractice, patient safety, financial fraud, drug diversion, regulatory violations, data and record security, etc. ) The hiring process in healthcare also important because of the value that employees can provide for an organization. “Good” employees enhance the value of organizations; they perceive potential risk and report or fix it, they provide important modeling for new... --- - Published: 2017-03-29 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/home-health-final-rule-exclusion-screening-condition-of-participation/ - Categories: Effect Of An Exclusion - Tags: Conditions, Home, Home Health, Home Healthconditions Of Participation, Participation By Paul Weidenfeld The new Final Rule issued by CMS revising the conditions of participation for home health agencies (HHAs) requires that providers “must ensure” that agencies providing services under arrangement have not been excluded from Medicare, Medicaid or any other federal health care program. Effective July 17, 2017, the rule also states that providers must ensure that such agencies have not had their billing privileges revoked, and that they have not been terminated or been debarred from participating in any government program. In making these requirements a condition of participation, CMS has created an affirmative screening obligation under which they have enforcement authority. I. Compliance as a Condition of Participation By making compliance with exclusion regulations a condition of participation, CMS has raised the stakes for failing to properly screen the exclusion status of vendors or contractors for HHAs while reaffirming the agency’s longstanding concerns about the participation of excluded persons in the Medicare Program. Specifically, CMS has a wide assortment of administrative remedies that can be imposed for failing to meet conditions of participation – including even the ability to terminate a provider from participation in the program itself – all of which are independent from the OIG’s enforcement authorities for exclusion violations. II. Guidance that Doesn't Guide Under the Final Rule, CMS may now hold an HHA liable for a State Exclusion in addition to a Federal Exclusion, by including Medicaid exclusion screening as a condition of participation. However, as there is no universal list of all Medicaid... --- - Published: 2017-02-13 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/pharmacies-targeted-exclusion-violations-oig-states/ - Categories: Medicare Enforcement - Tags: Action, Exclusion, Pharmacy, Pharmacy Exclusion Action In what appears to be a growing enforcement trend, the Department of Health and Human Services, Office of Inspector General (HHS/OIG) and State Medicaid Fraud Units are aggressively pursuing pharmacy retailers for exclusion violations. In recent investigations, pharmacies are being targeted for failing to screen prescribers as well as employing pharmacists who have been excluded from Federal and State health care programs. This new focus has resulted in sizable settlement recoveries, and evidences a broadening of the scope of Federal and State exclusion enforcement efforts. Significant State Exclusion Enforcement Actions New York Attorney General Eric T. Schneiderman entered into an agreement with a pharmacy in May 2016 to resolve allegations that it had billed Medicaid for prescriptions written by an excluded Medicaid provider. Between April 2010 and January 2013, the pharmacy submitted and received payment for approximately 4,600 Medicaid claims for prescriptions written by an excluded physician. Under Medicaid rules, prior to filling a prescription pharmacies are required to first determine whether the prescriber’s services are eligible for reimbursement. In this case, they had not done so and had filled and delivered prescriptions written by a provider ineligible to receive Medicaid reimbursement. As a result of the settlement, the pharmacy agreed to pay New York State $442,000 plus $36,000 in damages pursuant to the New York False Claims Act. In a statement, A. G. Schneiderman says, “My office will continue working to root out Medicaid fraud and recover unlawfully claimed funds, so that Medicaid can continue providing critical services for... --- - Published: 2017-02-01 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/excluded-dentist-pays-1-million-penalty/ - Categories: Medicare Enforcement - Tags: Dentist, Exclusion, Jersey, New, New Jersey Dentist Exclusion Exclusion Violation by Dentist "Sends a Strong Warning" The Office of the Inspector General's (OIG) announced last week that it had reached a settlement in excess of a million dollars with an excluded dentist for violations of the provisions of the regulations denying participation in federal health care programs by an excluded individual.  The terms of the settlement require the excluded dentist to pay $1. 134 Million in Civil Money Penalties and to agree to be excluded from participation in Federal Health care Programs for a period of 50 years! Dental Exclusion | Excluded Dentist Assumes the Identity of a Dead Colleague An investigation lead by the OIG found that a New Jersey dentist who had lost his license and been excluded from participating in federal health care programs managed to avoid these professional sanctions for almost seven (7) years. The dentist was excluded from participation in federal health care programs in 2000 as a result of licensure issues (he was suspended from practicing dentistry in 1999 and had his license revoked in 2004), but he was able to circumvent these sanctions by assuming the identity of a colleague in and maintaining that identity even after the colleague's death. In this way, the excluded dentist was able to re-start practicing in 2005 and to continue until 2012 during which time he owned, controlled, and managed a large New Jersey dental practice with multiple locations. An "Appropriate Resolution" for his Fraud and Putting Patients at Risk To resolve the case, the dentist agreed to pay... --- - Published: 2017-01-24 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-expands-exclusion-authority/ - Categories: Medicaid Enforcement - Tags: Authority, Exclusion, Expansion, Expansion Of Permissive Exclusion Authority, Permissive On January 12, 2017, the Office of Inspector General published a final rule finalizing revisions to its exclusion authorities. The final rule makes changes to key definitions that could have a significant impact on providers by broadening the scope of their exclusion screening obligation and enhancing exclusion enforcement by the agency. Effective February 10th, the final rule also authorizes new basis’ for permissive exclusions, makes the acquisition of information during investigations easier, creates a process for early reinstatement, and caps the Statute of Limitations at 10 years. OIG Expands its Exclusion Authority Through Definitional Changes Federal and State health care programs are prohibited from paying for items or services furnished, either directly or indirectly, by an excluded person or entity. The payment prohibition, as originally written, was limited to claims that were “submitted” and to the persons or entities that made the “submissions;” a limitation that did not account for the growing number of non-traditional reimbursement mechanisms (such as shared savings or performance-based payments). The final rule proposes to amend the definitions of “directly,” “indirectly” and “furnished” to “incorporate newer payment methodologies” simply by eliminating the “submission requirement. ” It redefines “direct claims” to include “the provision of an items or services for which one “request(s) or receive(s) payment from ... Federal health care programs;” and “indirect claims” to include items and services “that do not directly request or receive payment from Medicare, Medicaid, or other Federal health care programs, but that provide items and services to providers, practitioners, or... --- - Published: 2016-12-16 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/doj-announces-fca-recoveries-4-7-billion/ - Categories: Medicare Enforcement - Tags: 2016, 2016 False Claims Act Recoveries, Act, Claims, False, Recoveries DOJ Announces $4. 7 billion in FCA Recoveries The "Third Best Year" in False Claims Act History? The Department of Justice announced earlier this week that FY 2016 was its third best year in “False Claims Act History” with recoveries of more than $4. 7 billion in settlements and judgments. Though it as been trumpeted as DOJ's return to its record setting years, an examination of the numbers reveal that healthcare FCA recoveries have actually been remarkably consistent over the past seven years, and that they say more about the emphasis DOJ places on resolving “big” cases than they do about overall fraud enforcement. A Dependence on Large Cases Big settlements make for impressive press releases and are good for overall numbers, and FY 2016 was no exception. The “Top 5” settlements accounted for over 52% of all federal recoveries at 2. 5 billion, and total announced recoveries for these cases was a staggering $3. 55 billion! Following the playbook, the “Top 5” healthcare settlements accounted for a whopping 60% of all federal healthcare FCA recoveries at just a tick over $1. 5 billion. The dependency on large settlements is not new. Indeed, according to research that we have conducted, the five largest settlements consistently accounted for over 50% of recoveries in every calendar year fro 201-2014 just as it did in FY 2016. Healthcare Recoveries Remarkably Stable Despite the dependence on obtaining a few large settlements each year, DOJ's $2. 6 billion in healthcare FCA recoveries for FY 2016 continued... --- - Published: 2016-12-04 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/2016-oig-work-plan/ - Categories: Medicare Enforcement - Tags: Oig, Oig Plan Work, Plan, Work The Office of Inspector General’s 2016 OIG Work Plan contains two important projects that focus on the enforcement of exclusion rules by States and their Medicaid Fraud Control Units. Viewed in the context of the creation of a special task force in June of 2015, and other data we have cited to in the past year, it is clear that enforcement of exclusion rules and exclusion violations remain a priority for the agency. I. The Projects of 2016 OIG Work Plan In the first project, the OIG announced that it will determine the extent to which States are collecting the required ownership information in compliance with Federal and State regulations and whether States are verifying the information it receives by checking exclusion databases as they are required to do. In a separate study, the OIG will evaluate compliance with ACA, §6402 and consider whether States are conducting the required enhanced screenings for moderate and high-risk providers, and whether they are revalidating these Medicaid providers and suppliers as the act requires. II. Significance of 2016 OIG Work Plan Projects These studies are significant because many States, such as Texas and Louisiana, have expanded their disclosure provisions well beyond owners to include all employees, vendors and contractors.  These disclosure provisions typically include information on exclusions, suspensions and other adverse actions. Thus, in many states, in order to be in compliance with their enrollment agreement, providers will have to screen all employees, vendors and contractors with all State databases in addition to the LEIE... --- - Published: 2016-09-07 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-violations-net-record-penalties/ - Categories: Medicare Enforcement - Tags: Employment, Employment Of Excluded Pharmacist, Excluded, Pharmacist OIG Imposes Record $21. 5 Million in Penalties for Exclusion Violations! The OIG imposed a record $21. 5 million civil money penalties and restitution against an Ohio corporation that operates pharmacies and supermarkets in 34 states for exclusion violations involving the employment of excluded individuals and fulfilling prescriptions by excluded prescribers! The settlement alleged that the company filled prescriptions from 84 excluded pharmacists and directly employed 14 pharmacists that had been excluded from federal health care programs. The Office of Personnel Management participated in the investigation through its Office of Inspector General and confirmed that 14 direct employees had been debarred from participating in the Federal Employee Health Benefit Program (FEHBP). OPM received over $314,000 in penalties and $628,000 in restitution as part of the settlement. Federal Health Care Programs do not pay for items or services that are provided, either directly or indirectly, by excluded individuals and the Office of Inspector General also has the authority to impose Civil Money Penalties on providers that knowingly submit such claims. Providers that fail to screen on a monthly basis to identify excluded employees or vendors are considered to have knowningly submitted such claims related to such persons or entities. When the OIG announced last June that it had created a Special Litigation Unit dedicated to enhancing its enforcement of OIG Exclusion Requirements and Civil Money Penalty, it put the provider community on notice of its continuing commitment to enforce exclusion screening requirements and punish exclusion violations. Since that time, it has announced over... --- - Published: 2016-08-09 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/oig-exclusion-screening/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Obligations, Oig, Oig Exclusion Screening Obligations, Screening The Office of Inspector General (OIG) has steadily increased its enforcement of OIG Exclusion Screening violations since the issuance of its Special Advisory stressing the effect of an OIG Exclusion in May, 2013. Among other things, they have created a special unit to focus specifically on Civil Money Penalties (CMPs) (its favored enforcement tool), supported numerous prosecutions by both its Office of Audit and its Office of Evaluations and Inspections, and sought greater regulatory authority from Congress. This article was originally directed (and is still intended) to give a basic tutorial on what an exclusion is, how it effects them, and what they can do to protect themselves. I. What is an OIG Exclusion? The Department of Health and Human Services (HHS) is responsible for administering the Medicare and Medicaid Programs and it decides who may receive benefits under these programs as well as who will be allowed to provide them. When it is determined that a person or entity will not be permitted to provide services to the program, that person or entity is said to be “excluded. ” The authority to exclude individuals and entities from Federal health care programs has been delegated by the Secretary of HHS to the OIG. There are two types of OIG exclusions, mandatory and permissive, and both have the effect of barring an individual or entity from participating in all Federal health care programs until such time, if ever, that their privilege has been reinstated. Mandatory exclusions last a minimum of 5... --- - Published: 2016-08-02 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/doj-doubles-false-claims-act-penalties/ - Categories: Medicare Enforcement - Tags: Act, Claims, False, False Claims Act The False Claims Act is the primary civil enforcement tool utilized by the federal government in its fight against fraud generally, and, in particular, Medicare and Medicaid Fraud. Already an extraordinarily useful statute for government prosecutors both in terms of ease of use and in terms of the penalties and damages that may be recovered, the Department of Justice has further raised the stakes by virtually doubling the civil monetary penalties that may be assessed. The action, which was effective August 1, 2016, was taken in accordance with the provisions of the Bipartisan Budget Act of 2015, and this article provides an overview of the False Claims Act and discusses the scope of the increases in penalties that are being implemented. I. Background of the Federal False Claims Act Sometimes referred to as “Lincoln’s Law,” the False Claims Act was first passed in 1863 in response to war profiteering. Among its provisions were measures intended to encourage the disclosure of fraud by private persons through the filing of a qui tam suit. The term qui tam is taken from a Latin phrase meaning “he who brings a case on behalf of our lord the King, as well as for himself... ” Under the qui tam (also commonly referred to as “whistleblower”) provisions of the statute, a private person (often referred to as a “relator”) may bring a False Claims Act lawsuit on behalf of, and in the name of, the United States, and possibly share in any recovery made by the... --- - Published: 2016-05-04 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/oig-permissive-exclusion-authority/ - Categories: Medicaid Enforcement - Tags: Criteria, Exclusion, Permissive, Permissive Exclusion Criteria On April 18, 2016, the Department of Health and Human Services, Office of Inspector General (HHS-OIG) issued updated criteria for assessing and evaluating the imposition of permissive exclusions under Section 1128(b)(7) of the Social Security Act. The update replaces the 1997 Federal Register notice and demonstrates the OIG’s ongoing interest in the implementation and enforcement of its exclusion authority. Background The Office of Inspector General (OIG) uses its exclusion authority to protect Federal health care programs from individuals or entities “whose continued participation constitutes a risk to the programs and their beneficiaries. ” As discussed in other Exclusion Screening articles, Medicare will not pay for any items or services furnished, directly or indirectly, by an excluded individual or entity, and the failure to screen for exclusions can result in civil money penalties and overpayments. The OIG’s permissive exclusion authority authorizes the OIG to impose a period of exclusion in a number of different circumstances. However, the update focuses primarily on the evaluation of health care fraud cases, and this article outlines the criteria that the OIG will consider in making exclusion determinations in these matters. The OIG’s Evaluation of Risk to Federal Health Care Programs The OIG has a number of different administrative options. According to the update, the OIG evaluates which administrative action to impose based on where an individual or entity falls on a spectrum. The OIG’s spectrum considers the individuals or entities involved and the risks posed to patients and federal health care programs by their continued... --- - Published: 2016-03-04 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/applying-for-reinstatement/ - Categories: Exclusion Screening Basics - Tags: Exclusion, List, Removal, Removal From Exclusion List I. The OIG Reinstatement Process Most exclusions are imposed for a definite time period. The question for an excluded individual or entity is: What happens at the end of the exclusion period? The answer is that the excluded individual or entity MUST apply for OIG reinstatement. The U. S. Department of Health and Human Services (HHS) will NOT automatically reinstate the person or entity at the end of the exclusion period. An excluded provider may apply for reinstatement 90 days before the date specified on his, her, or its exclusion notice letter. To apply for reinstatement the excluded individual or entity must send a written request to: HHS, OIG, OIAttn: ExclusionsP. O. Box 23871Washington, DC 20026(202) 691-2298 (Fax) The Office of the Inspector General (OIG) will send the provider Statement and Authorization forms to complete, notarize, and return. OIG will review these forms and will send the provider a written notification of its final decision. This process may take 120 days or longer to complete. II. Denial of OIG Reinstatement If the application for reinstatement is denied, the excluded individual or entity may submit evidence and a written argument against the continued exclusion; a written request to present written evidence and oral argument to an OIG official; or documentary evidence and a written request to present oral argument. The evidence, written argument, or written request for a hearing must be submitted 30 days after the provider receives the written notice of OIG’s final decision. After reviewing the materials (or after the... --- - Published: 2016-03-04 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/compliance-hotlines/ - Categories: Compliance Hotlines - Tags: Compliance, Compliance Hotline System, Hotline, System By Paul Weidenfeld, March 4, 2016. An essential element of all compliance plans is developing and promoting “effective lines of communications. ” In support of that element, Health and Human Services Office of Inspector General (HHS/OIG) has been urging providers to adopt anonymous compliance hotlines since 1998. CMS, on the other hand, actually requires that Fee-For-Service Contractors (by its 2005 Guidance), and Managed Care and Prescription Drug Contractors (through manual provisions) have “mechanisms that permits anonymous reporting. ” But many providers, while complying, view hotlines with suspicion. They fear that a “successful” compliance hotline might incentivize “whistleblowers” and ultimately result in additional risk and cost to their organization. Though understandable, this fear is misplaced. Properly implemented and supported, hotlines provide valuable support to compliance plans and overall risk management programs. Rather than increasing risk and costing money, compliance hotlines demonstrably decrease risk and save money. Here’s how: I. Tips are the Most Common Means of Detecting Fraud Fraud accounts for an estimated 10% of healthcare spending (almost $1 Billion in 2013). The best way to reduce fraud’s impact is through early detection and quick resolution. According to a recent report on occupational fraud by the Association of Certified Fraud Examiners (ACFE) “tips” are easily the most common means of detecting fraud. It found that over 40% of all cases were detected by a tip — more than twice the rate of any other detection method – and as the percentage of detections by tip increases, detection by other, external means decrease.... --- - Published: 2015-10-12 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-loophole-medicaid-managed-care/ - Categories: Medicaid Enforcement - Tags: Care, Exclusions, Managed, Medicaid, Medicaid Managed Care Exclusions In August, we discussed an OIG audit, which revealed that Medicaid providers who were terminated for cause were often able to still participate in other state Medicaid programs. Through this audit, OIG discovered that many providers were able to take advantage of a particular exclusion loophole within the Medicaid Managed Care program. Specifically, OIG discovered that 25 of the 41 states that participate in Medicaid Managed Care do not require providers to enroll in their state’s Medicaid program. The states instead permit providers to perform Medicaid managed care services based on contracts with managed care companies. Identifying and Terminating This loophole creates two unique problems for state Medicaid programs. First, it is much harder for a state to keep track of the providers participating in its Medicaid Managed Care program if the state does not require providers to actually enroll. In addition, if a state does not know exactly who is participating in its Medicaid Managed Care Program, then it is also difficult to search for providers to ensure that they were not terminated from participation in another state as required by ACA 6501. Second, it is very difficult for a state to terminate a provider from participating in its Medicaid program if it has no contractual relationship with that provider. In other words, it is very hard to end a relationship with someone if there was never a mutual agreement to actually begin the relationship. Solution in Sight? OIG recommended that CMS require state Medicaid programs to enroll Medicaid... --- - Published: 2015-09-23 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/gaps-in-oig-and-state-exclusion-lists/ - Categories: Effect Of An Exclusion - Tags: Exclusion, Incomplete, Incomplete State Exclusion Lists, Lists, State The failure to report excludable offenses by state Medicaid offices and licensing boards is a longstanding issue for the OIG. Recent OIG audits and reports have confirmed these state failures to report. For example, an OIG study released in August found that over 12% of terminated providers were able to continue participating in other state Medicaid programs because states were not sharing terminated provider information. In addition, two recent Medicaid Fraud Control Unit (MFCU) audits discovered that they routinely failed to timely report conviction information to the OIG and sometimes did not report them at all. Reporting failures lead to gaps in the OIG Exclusion List (LEIE) because the OIG cannot exclude an individual if the OIG is never informed of the state’s conviction, termination, or suspension of providers. Such failures to report are important because the information that would have been reported can lead to exclusion violations, which are listed on the LEIE. But, state compliance failures are not the only cause of gaps in OIG and State exclusion lists – as we discuss, no matter who is at fault, the provider may pay for anyone’s mistake. I. The OIG Exclusion List Has Limited Search Capabilities One important reason providers should not rely on screening only the LEIE is that its search function is extremely narrow. If an excluded individual uses a different name, such as a middle or maiden name, an LEIE search using the person's first and last names may not produce any results. For example, J.... --- - Published: 2015-09-08 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/excluded-provider-health-care-fraud/ - Categories: Medicare Enforcement - Tags: Billing, Billing For Services Of Excluded Individuals, Excluded, Individuals, Services Of Excluded Individuals In February, we reported that the Michigan Attorney General secured a racketeering and health care fraud conviction against an excluded Michigan podiatrist. The podiatrist participated in an elaborate health care fraud scheme with another Michigan provider. In early July, the Michigan Attorney General successfully convicted the doctor who knew or should have known that the podiatrist was excluded. Health Care Fraud Conviction Details The Attorney General’s investigators determined that the provider hired a former podiatrist who was convicted of health care fraud in 2003. The podiatrist was subsequently excluded from participation in the federal health care programs for a period of 25 years. The provider billed private insurance and the government for the excluded podiatrist’s medical services as if he performed them. Trial testimony indicated that the provider made payments to the excluded podiatrist from the same account where health care program payments were deposited. For entering into this scheme, the provider was convicted of racketeering (20-year felony), thirteen counts of health care fraud (4-year felony), and five counts of Medicaid fraud (4-year felony). Up to $200,000 in fines accompanied the convictions. Takeaway The Michigan provider was held liable because he “knew or should have known” that the podiatrist he contracted with was excluded from participation in the federal health care programs. The OIG and state Attorney Generals are working to end health care fraud by seeking out providers who employ or contract with excluded persons or entities. The best way to protect yourself from liability is to screen all... --- - Published: 2015-09-01 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-corporate-integrity-agreement/ - Categories: Medicare Enforcement - Tags: Boise, Boise V Cephalon, Cephalon In late July, a federal district court in Pennsylvania joined in the flurry of False Claims Act (FCA) decisions. These decisions further interpreted the ACA’s amendments to the law. The court in United States ex rel. Boise v. Cephalon, Inc. considered two important issues. The issues regarded when a party has an obligation to pay the government, and when a failure to do so could result in reverse false claims liability. Providers should be on high alert and ensure that they are in compliance with all requirements. This includes the requirement to screen employees monthly in order to avoid being OIG's next false claims target. Background The defendant in Cephalon failed to comply with its Corporate Integrity Agreement (CIA) and OIG sought repayment. OIG alleged that they failed to comply with the CIA, which caused reverse false claims and produced FCA liability. Cephalon, a drug manufacturer, argued that it could have only had an obligation to pay penalties under the CIA if HHS-OIG actually demanded payment. The relator argued that Cephalon’s obligation to pay actually arose when it breached the CIA’s reporting requirements. The court disagreed with Cephalon and instead held for the relator. The court found that a CIA imposes contractual obligations through reporting requirements. Furthermore, a breach of these contractual obligations could cause a company to be liable for reverse false claims even if OIG had not yet demanded payment. Finally, the court elaborated that “specific contract remedies” like specific penalties create a “less contingent obligation to pay. ” Takeaways The... --- - Published: 2015-08-27 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/2015-mid-year-exclusion-enforcement-action-review/ - Categories: Medicare Enforcement - Tags: 2015, 2015 Mid Year Update, Mid Year, Update OIG has been busy cracking down on providers who employ or contract with excluded persons or contractors. In fact, by the end of July OIG settled 27 exclusion violation cases through investigations or self-disclosures. By way of reminder, there were 60 enforcement actions related to OIG exclusion violations in 2014. Following is our 2015 mid-year review of OIG's enforcement against those who employ or contract with excluded providers. Civil Monetary Penalties In six months, OIG recouped $3. 79 million from providers who knew or should have known that an employee was excluded from participation in the federal health care programs. A third of the settlements in the past six months resulted in payments between $100,000 and $250,000 per provider. The Civil Monetary Penalties (CMPs) returned in each enforcement action range from $10,000 to $431,000 and an overwhelming majority of the cases only involve one excluded individual. In fact, only 4 of the 27 enforcement actions this year involved more than one excluded provider. This goes to show that the penalty a provider may face for employing or contracting an excluded person varies widely depending on exactly how many items or services that person provided. Industry Breakdown One trend that remains steady is that nursing homes continue to be the industry hit the hardest with enforcement actions. Following behind nursing homes were hospitals and home health agencies with four enforcement actions each so far this year. We expect that nursing homes and home health agencies will remain hot beds for OIG... --- - Published: 2015-08-26 - Modified: 2026-01-05 - URL: https://exclusionscreening.com/excluded-individual-elaborate-health-care-fraud-scheme/ - Categories: Medicare Enforcement - Tags: Ambulance, Company, Excluded, excluded ambulance company owner, Owner The owner of a New Jersey ambulance company was indicted for health care fraud in mid-August of 2015. The owner was excluded from participation in the federal health care programs after being convicted of defrauding New Jersey health care programs in 2003. This is just the latest in a steady stream of health care related enforcement actions by state attorney generals. Background New Jersey prosecutors allege that the provider has been the owner and operator of a New Jersey ambulance company to which Medicare and Medicaid have paid out a combined $7. 5 million since 2010. The provider allegedly hid his involvement in the company by paying employees in cash. The defendant has owned and operated the ambulance company since 2005, which is only two years after he was excluded from participation in the federal health care programs for a period of 11 years. The provider now faces a 17-count federal indictment with a possible sentence of 30 years in prison for conducting the health care fraud scheme. Takeaways It may be difficult to protect yourself from individuals like this New Jersey provider who explicitly sought to defraud the federal health care programs. Providers should, however, try to protect themselves by conducting monthly exclusion screening searches of their employees and contractors. Providers should also maintain proper records of these searches. States, like the federal government, are actively pursuing those who are in violation of federal health care regulations. Remember, compliance is always the best policy! Are you taking the necessary precautions to ensure you are... --- - Published: 2015-08-21 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-screening-required-in-united-states-territories/ - Categories: Exclusion Screening Basics - Tags: Medicaid, Puerto Rico, Puerto Rico Medicaid Screening And Virgin Islands Medicaid Screening, Screening, Virgin Islands Our experts at Exclusion Screening, LLC maintain fact sheets that contain the screening requirements for providers in every state, including those states that do not currently maintain a separate excluded or terminated provider list. However, Medicaid participation and adherence to exclusion screening requirements does not stop with the fifty states. United States territories like Puerto Rico and the U. S. Virgin Islands also participate in Medicaid, and therefore, providers must comply with the same screening requirements as United States Medicaid providers. I. A Closer Look Through our research, we analyzed and compiled the exclusion screening requirements in Puerto Rico, the U. S. Virgin Islands, the Northern Mariana Islands, and Guam. A summary for each territory follows. II. Puerto Rico Puerto Rico’s Medicaid program does not maintain a separate excluded provider list and does not demand that providers conduct independent exclusion screening. Instead, private companies, like Molina Healthcare, which contracts with Puerto Rico Medicaid, conduct exclusion screening searches before accepting a provider’s Medicaid enrollment application. The contracted healthcare company continually reviews review the exclusion lists monthly thereafter. III. The U. S. Virgin Islands The U. S. Virgin Islands, on the other hand, require providers to disclose quite a bit of information pertaining to exclusions. When a provider enrolls in the Virgin Islands’ Medicaid program, he must disclose whether: the provider; any person or entity that has a direct or indirect ownership interest of 5% or more of the provider; any person or entity with an interest in any subcontractor that the... --- - Published: 2015-08-20 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/compliance-hotline/ - Categories: Compliance Hotlines - Tags: Compliance, Compliance Hotline, Compliane Hotline System, Hotline, Systems One of the seven steps to an effective compliance plan is to develop effective lines of communication. While it is important to foster open lines of communication within your practice, many employees may fear retribution. Hence, they may feel more comfortable reporting complaints anonymously or at least to a third-party vendor. Fortunately, providing an outside reporting mechanism such as the hotline offered by Compliance Hotline is an extremely cost effective solution. Within this article we will address some of the benefits of outsourcing your compliance hotline. I. Minimize Risk by Fostering Confidential Compliance Hotline Reporting Under Sarbanes-Oxley, certain whistleblowers are protected from employer retaliation for reporting instances of fraud. This provision permits an employee to file a complaint with the Secretary of Labor if he is discriminated against for “blowing the whistle. ” However, many employees may not be educated about this law, or may still fear retribution. Therefore, they may not file a report to an internal department. By providing an outside confidential report line, like Compliance Hotline, your employees will be more comfortable reporting issues. You will also become aware of any lurking issues within your practice more quickly. II. Protect your Practice from Fraud and Liability with the Compliance Hotline According to the Association of Certified Fraud Examiner’s Report to the Nations, tips are the most common mode of detecting fraud cases within organizations. Tips have a 40% fraud identification rate. Internal audits and management reviews follow as the second and third best detection methods. They have 15% and 13%... --- - Published: 2015-08-14 - Modified: 2025-09-12 - URL: https://exclusionscreening.com/false-claims-act-liability-overpayments/ - Categories: Effect Of An Exclusion - Tags: Identifying, Identifying Overpayments, Overpayments In early August of 2015, the Southern District of New York (SDNY) provided insight as to when the 60-day clock for returning an overpayment begins to run under the Patient Protection and Affordable Care Act of 2010 (ACA). This decision is particularly relevant to screening for exclusions because the government has started to penalize providers who submit claims for services provided directly or indirectly by an excluded individual or entity for the greater penalty of submitting a false claim. Simply stated, the government now views claims as legally false if an excluded person provided any part of that claim. This makes providers possibly liable pursuant to the false claims act. The court’s additional clarity on when the 60-day clock begins to run for false claims act liability may be the OIG’s next tool in retrieving Federal dollars from those providers who fail to screen their employees or contractors monthly. Therefore, those providers could be in receipt of overpayments for monies received from services provided by excluded persons or entities. I. Background - False Claims Act The Fraud Enforcement and Recovery Act (FERA), enacted in 2009, amended the False Claims Act and added a “reverse false claims” provision. This reverse false claims provision imposes liability of $5,500 to $11,000 per false claim on persons who “knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the Government. ” The term “knowingly” includes persons who have “actual knowledge of the information,” as well as those who “act in deliberate ignorance”... --- - Published: 2015-08-11 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/60-day-rule-exclusion-violations/ - Categories: Effect Of An Exclusion - Tags: 60 Day, 60 Day Rule, Rule The Affordable Care Act (ACA) creates a 60‑day window to report and return overpayments from Medicare or Medicaid after the date on which the overpayments were identified. If the overpayments are not returned within 60 days, then they can become false claims. Though this has been the law since 2010, we are just now seeing how this plays out and how it may have a significant impact on OIG exclusion violations. I. Recent DOJ Action In United States ex rel. Kane v. Healthfirst, Inc. , et al. , Healthfirst is alleged to have violated the False Claims Act (FCA) because it did not fulfill its repayment obligation until nearly two years after it was notified about the potential overpayments. Ruling on Healthfirst’s Motion to Dismiss, the court considered the meaning of “identify” as it is used in the ACA.  The ACA left ambiguity regarding when exactly the 60-day clock begins to run. The court held that an overpayment is identified at the moment a provider is “put on notice of a potential overpayment,” and not when the full extent of an overpayment is “conclusively ascertained. ” As such, even though the hospital has repaid the money, it is potentially liable under the FCA. The same day the court issued this important order, the U. S. Attorney’s Office in Georgia announced the first settlement under the FCA for the retention of overpayments in the form of credit balances. In that case, according to the press release, the provider paid $6. 88 million because... --- - Published: 2015-08-10 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/excluded-medicaid-providers/ - Categories: Medicaid Enforcement - Tags: Excluded, Excluded Medicare Part D Providers, Medicaid, Medicaid Termination Of Excluded Providers, Providers, Termination   OIG Audit Findings In a recently released audit, the OIG found that despite the ACA requirement that states terminate Medicaid providers already terminated in another state, 12% of providers already terminated for cause in 2011 in one state (295 out of a sample of 2,539) were still participating in other state Medicaid programs as of January of 2014! There is a lack of state to state coordination identified in both this audit and one issued last March, and a lack of state to Federal coordination identified in separate OIG audit reports. This strongly reinforces our suggestion that providers screen their employees, vendors and contractors on all available State Exclusion Registries in addition to the LEIE and the SAM! Exclusion, Termination and the ACA In practical terms, to implement section 6501 of the ACA, states must first find the providers who are terminated from federal healthcare programs. Then, states must identify whether any terminated providers are participating in their Medicaid program. Finally, they must take action to terminate the provider from its own Medicaid program. According to the report, this is defeated by a general lack of coordination caused in large part by a lack of uniformity of terminology among not only the states, but in existing Federal and state databases. For instance, exclusion and termination are synonymous in many states, but they have distinctly different meanings for CMS. This is also true with such terms as suspension, disbarment, revocation and sanction. Furthermore, what constitutes “cause” in one state may not in another... --- - Published: 2015-07-29 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/false-claims-act-oig-exclusion-violations/ - Categories: Medicare Enforcement - Tags: Action, Clinic, Health, Mental, Mental Health Clinic Action DOJ Pursuing Action on Two Separate OIG Exclusion Violations The U. S. Attorney’s Office in Philadelphia filed a False Claims Act case last week based primarily on OIG exclusion violations. The complaint alleges that the defendant filed several documents concealing his exclusion and his role in Mental Health Clinics ostensibly run by his wife. Medicare and Medicaid do not pay for services provided, either directly or indirectly, by someone who is on the OIG List of Excluded Individuals (LEIE) or on a State Medicaid Exclusion List. The lawsuit comes on the heels of a suit with similar allegations brought by that office in May. It further evidences the increasing interest of OIG and DOJ in enforcing exclusion regulations and exclusion screening requirements. The filing was announced by United States Attorney Zane David Memeger. He stated that, “this civil complaint reflects our focus on pursuing individuals who defraud Medicaid and Medicare, especially after they have previously defrauded those programs and been barred from participating in them. ” The complaint also alleges fraudulent billing for services provided without proper supervision and by unqualified persons. While both cases involve similar fact patterns (persons concealing their exclusion status and involvement in a company) and were filed within months of each other, it is significant to note that they arose in completely different ways. The most recent case's complaint is a whistleblower lawsuit that was brought to the government by an ex-employee. The older case, however, arose from an OIG led investigation. Final Thoughts There are two clear takeaway points from... --- - Published: 2015-07-23 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/ann-maxwell-exclusion-violations-part-d/ - Categories: Medicare Enforcement - Tags: Excluded, Excluded Medicare Part D Providers, Medicare, Part D, Providers Assistant Inspector General Testifies before Congress Ann Maxwell, the Assistant Inspector General for Evaluation and Inspections, recently testified before Congress. She argued that the Centers for Medicare and Medicaid Services (CMS) had not exercised “sufficient oversight of plan sponsors,” and “needed to strengthen its controls” in order to prevent payments for drugs “to providers excluded from Federal health care programs. ” She further explained that “it is important that claims for drugs prescribed by excluded providers be denied to protect beneficiaries from inappropriate or even harmful services. ” Maxwell appeared to lay much of the responsibility on CMS noting that the “OIG found that controls failed to prevent Part D payments for drugs prescribed by excluded providers,” resulting in exclusion violations. Also, she noted CMS lacked a “claims processing edit” that would reject prescriptions written by excluded providers. Impact of Exclusion Violations on Medicare Part D Maxwell’s testimony coincided with the release of an OIG Portfolio “Ensuring the Integrity of Medicare Part D,” OEI-03-15-0018. Though the portfolio also focused on other Part D program integrity and exclusion issues, OIG Exclusion Violations played a major role in both the testimony and the portfolio. Ms. Maxwell, echoing a finding in the portfolio, referenced two previous OIG studies dealing with this issue. In one study, the OIG found that plan sponsors paid “gross drug costs totaling $15 million over a 3-year period for prescriptions written by excluded providers. ” (“Review of Excluded Providers in the Medicare Part D Program A-07-10-06004," click here to read). The OIG concluded... --- - Published: 2015-07-01 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/special-litigation-unit/ - Categories: Medicare Enforcement - Tags: Exclusion, Oig, Oig Exclusion Unit, Unit Exclusion Screening, LLC has been chronicling the Office of Inspector General’s (OIG) interest in exclusion enforcement for quite some time. Hence, yesterday’s announcement that the OIG created a special litigation unit focusing on Civil Money Penalties (CMP) and Exclusions comes as no surprise to us. Only two weeks ago we published an article on the OIG’s increasing enforcement efforts. In that article we concluded that: “The evidence strongly supports the conclusion that OIG’s involvement in exclusion enforcement is increasing... enforcement interest and involvement spread throughout the agency... . ” This followed a January article discussing increasing enforcement in 2014. There has been no formal announcement on the agency website. Therefore, the details of the unit are not yet known. On June 30, 2015, at the annual meeting of the American Health Lawyers Association, it was announced that the unit was actually formed in March. However, it is not yet fully staffed.   Need to know more about what your organization needs to do in terms of screening for exclusions? Call Exclusion Screening at 1-800-294-0952 or fill out the form below for more information and to hear how Exclusion Screening can save your organization from civil monetary penalties.   hbspt. forms. create({ portalId: "4660270", formId: "37f27296-30f9-41f4-b30e-af563534fea8", region: "na1" });   Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime healthcare lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should you have any questions at: pweidenfeld@exclusionscreening. com or 1-800-294-0952. --- - Published: 2015-06-30 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-screening-contractors-vendors/ - Categories: Exclusion Screening Basics - Tags: Contractors, Screening, Screening Of Contractors By now, providers should be aware that the Office of Inspector General (OIG) requires exclusion screening of contractors and vendors, in addition to employees, if they provide items or services that are payable by Federal health care programs. This article identifies the OIG’s guidance on the issue, explains the difficulties it poses, and concludes by suggesting a framework for applying the guidance to screening vendors and contractors. OIG Guidance: An Emphasis on Patient Care – A Focus on Payment The OIG states that its emphasis on screening vendors and contractors for exclusions regards "items or services integral to the provision of patient care. "This is sensible as many exclusions are the result of licensing issues and drug offenses which could result in a risk of harm to patients. With that said, the OIG’s guidance focuses heavily on considering the nexus between vendor/contractor activities and any resulting claims. Providers are advised to review the “job category or contractual relationship” of each and every contractor and vendor. Then, if the provider determines that the vendor or contractor provides items or services payable “directly or indirectly, in whole or in part ... by a Federal health care program,” the vendor or contractor should be screened for exclusions monthly. The Breadth of the Guidance The OIG guidance is so broad that it is difficult to apply in a meaningful way. For instance, Exclusion Screening, LLC is sometimes asked by providers who make claims that include facility fees or some other overhead component whether they are obligated... --- - Published: 2015-06-22 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-screening-basics/ - Categories: Exclusion Screening Basics - Tags: Basics, Exclusion, Medicare, Medicare Exclusion Basics Exclusion Screening Is Mandatory Providers of medical services that participate in Federal or State Health Care Programs are required to screen all of their employees, vendors, and contractors monthly to ensure that none have been excluded from either the Medicare or Medicaid programs. Practices that fail to meet this requirement risk Civil Monetary Penalties (CMPs) and overpayments because Federal and State regulations prohibit payment for any item or service that was provided, directly or indirectly, by an excluded person. Enforcement cases involving the employment of excluded persons are increasing dramatically. The imposition of CMPs more than doubled from 2013 to 2014, and recent case investigations have been supported by data analysis projects by the Office of Audit Services and the Office of Evaluation and Inspections. In light of the increasing enforcement efforts and the potential consequences, it is critical that providers gain a basic understanding of the issues relating to Exclusion Screening and how they can be addressed. What is an Exclusion? HHS/OIG has the authority (by delegation from the Secretary) to deny persons and entities the ability to participate in federal healthcare programs. When such an action is taken by the OIG, that person or entity is said to be “excluded” and placed on the List of Excluded Individuals and Entities (commonly abbreviated as “LEIE”). Federal exclusions can be either mandatory or permissive, but both have the effect of barring participation in all federal healthcare programs until such time, if ever, that the government agrees to reinstatement. Mandatory exclusions last a minimum of 5 years... --- - Published: 2015-06-16 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/exclusion-case-review-1st-quarter-of-2015-evidences-an-increase-in-enforcement-efforts-by-oig/ - Categories: Medicare Enforcement - Tags: Excluded, Excluded Provider Project, Project, Provider (This article was originally posted in the National Alliance of Medical Auditing Specialists' "Tip of the Week") At Exclusion Screening, we keep track of all of the exclusion cases reported by the OIG and analyze them for any number of obvious reasons. At first glance, the cases reported in the 1st quarter of 2015 seem fairly unremarkable as they show only small increases in the number of cases reported, and the CMPs imposed, and seem to maintain the slow, steady rise of the previous years. However, a closer examination of the cases strongly suggests that the OIG is picking up the pace of exclusion enforcement, and that it may even be headed toward a national exclusion enforcement project. I. Increasing Involvement in Active Investigations As we indicate above, the overall case numbers and CMPs imposed remained fairly consistent in the 1st quarter. However, a more focused analysis of the cases and their data, when compared with the cases reported in the previous years, provides strong evidence that direct OIG involvement in exclusion investigations and exclusion enforcement is clearly on the rise. Here’s how we reach that conclusion. Looking at the case data from 2010 through 2013, it is reasonable to conclude that OIG involvement in exclusion enforcement principally took the form of processing self disclosures. In 2013, for instance, 82% of all exclusion cases reported on the OIG website were self disclosure cases meaning less than 1 in 5 exclusion cases (18%) were investigated on front end by the OIG.... --- - Published: 2015-06-16 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-fca-settlements-excluded-persons/ - Categories: Medicare Enforcement - Tags: Action, Exclusion, Health, Home, Home Health Exclusion Action The Department of Justice (DOJ) recently announced two new False Claims Act (FCA) settlements involving excluded persons. The first was a $6. 5 million FCA settlement with a Nashville Home Health Agency. The services of a private duty nurse were identified in both settlement documents and the press release as an important component of the settlement. Although, the exact amount attributable to the excluded employee was not stated. In addition, it is significant that the case was investigated by the Tennessee Medicaid Fraud Unit and the Office of Inspector General (OIG). It is also significant that the settlement included State FCA violations as well as violations of the Federal FCA. The second case is also of significant interest. In U. S.  v.  John Hastings, DOJ took the unusual path of filing a detailed lawsuit asserting how the defendant knowingly and intentionally skirted the exclusion rules and billed Medicare even though a settlement had already been reached by the parties. Contemporaneous with the filing of the suit, DOJ and the defendant asked the court to enter a consent judgment in which the defendant agreed to extend his exclusion and pay the government $200,000. 00. This case also stands out because instead of arising out of a whistleblower suit, as most FCA cases do, this case was generated directly from an OIG investigation. This further evidences our stated view of an increasing interest in enforcement by the OIG in exclusion matters. The OIG is cracking down on providers who don't screen for exclusions. Call us at 1-800-295-0952 or fill... --- - Published: 2015-05-17 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/hhs-oig-illinois-exclusion/ - Categories: Medicare Enforcement - Tags: Employment, Employment Of Excluded Nurse, Excluded, Nurse Home Health Agency Excluded for Employing Excluded Nurse HHS/OIG recently issued a press release announcing that it had excluded an Illinois home health agency participation in all Federal health programs as a result of its employment of an excluded nurse. OIG's investigation revealed that the home care service had billed the Federal health care programs for services provided by the excluded nurse to both Medicare and Medicaid beneficiaries. An Unprecedented Move by HHS/OIG As far as we can tell, this is the first time that this has been the basis of an exclusion, and it further evidences the ongoing enforcement interest that the OIG has in exclusion violations.  The exclusion became effective March 19, 2015, and participation in Federal health care programs for a period of three years. It is also worthy of note that the OIG staffed the case with two Senior Counsels and a Paralegal Specialist, Eula Taylor.   Are you taking the necessary precautions to ensure you are not working with an excluded entity? We know it can be difficult to screen every Federal and State exclusion list. Call Exclusion Screening at 1-800-294-0952 or fill out the form below to hear about our cost-effective solution and for a free quote and assessment of your needs. hbspt. forms. create({ portalId: "4660270", formId: "37f27296-30f9-41f4-b30e-af563534fea8", region: "na1" }); Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime health care lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should... --- - Published: 2015-04-29 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/mfcu-annual-report/ - Categories: Medicaid Enforcement - Tags: Actions, Exclusion, Mfcu, Mfcu Exclusion Actions I. Gains in State Exclusion Enforcement Efforts Highlighted The Office of the Inspector General's (OIG) annual Report for the State Medicaid Fraud Control Units (MCFUs),1 released earlier this week, announced that one third of all OIG Exclusions (1,337 of 4,017) were the result of MFCU investigations, prosecutions, and convictions. We also note that licensure revocations and patient abuse (both primarily State related issues) accounted for an additional 1,933 exclusions at 1,744 and 189 respectively according to the HCFAC report issued in March.  State issues and State efforts were a large percentage of last year's exclusions.   II. State Initiated Exclusion by MFCU The Annual Report also highlighted a State initiated exclusion in which the West Virginia MFCU entered into a civil agreement with the owner of a durable medical equipment (DME) company. The DME company allegedly collaborated with an excluded provider to bill both Medicare and Medicaid for back braces that were provided by the excluded company. After submitting the charges to Medicare and Medicaid, the DME company allegedly kept ½ of the reimbursement and passed the remaining monies on to the excluded company using false invoices to support the billing. Are you taking the necessary precautions to ensure you are not working with an excluded entity? We know it can be difficult to screen every Federal and State exclusion list. Call Exclusion Screening at 1-800-294-0952 or fill out the form below to hear about our cost-effective solution and for a free quote and assessment of your needs. hbspt. forms. create({ portalId: "4660270", formId: "37f27296-30f9-41f4-b30e-af563534fea8", region: "na1" });   Paul Weidenfeld, Co-Founder and... --- - Published: 2015-04-26 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/medicare-medicaid-exclusion-screening-compliance/ - Categories: Medicaid Enforcement - Tags: Compliance, Exclusion, Exclusion Screening Compliance, Screening Since August 2014, the Office of Inspector General (OIG) has collected roughly $3. 75 Million in Civil Money Penalties (CMPs) in cases involving the employment of persons that have been “excluded” from Medicare. This amount exceeds the total CMPs assessed by OIG on this issue in all of 2013. This continues an established trend. The number of exclusion cases has more than doubled over the last three years. The OIG specifically added exclusion violations to its Self Disclosure Protocol and followed that with new guidance on the issue within a matter of weeks last spring. Furthermore, even the Office of Audit Services has become involved with a data analysis project that supports enforcement efforts.  Considering this increasing interest, the failure to properly screen for excluded employees or contractors has become a real and tangible risk for providers that should not be ignored. I. What is An Exclusion? The Department of Health and Human Services (HHS) is responsible for administering the Medicare and Medicaid Programs and it decides who may receive benefits under these programs as well as who will be allowed to provide them. When it is determined that a person or entity will not be permitted to provide services to the program, that person or entity is said to be “excluded. ” The authority to exclude individuals and entities from Federal health care programs has been delegated by the Secretary to the OIG.  There are two types of exclusions, mandatory and permissive, and both have the effect of barring an individual or entity from participating... --- - Published: 2015-04-20 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-special-advisory-bulletin/ - Categories: Exclusion Screening Basics - Tags: Advisory, Bulletin, Special, Special Advisory Bulletin The Office of the Inspector General (OIG) Broadly Interprets Exclusion Regulations OIG's Demonstrated Interest in Exclusion Screening and Forewarning of Increased Enforcement Efforts The OIG's Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs explains the types of conduct that could violate the payment prohibition, which regards items or services provided by excluded persons, and the potential administrative sanction checks for employing excluded persons or contractors. The advisory was issued less than a month after OIG specifically amended its Self-Disclosure protocol to include exclusion violations. Although the advisory bulletin provides some guidance on the screening of employees and contractors, it is not very helpful. Thus, the timing of the advisory and its emphasis on enforcement strongly suggested that OIG would expand its efforts. Subsequent events have shown this to be true. I. The Regulations on Payment and Penalties The regulation prohibiting payment for services furnished or provided by excluded persons, 42 CFR § 1001. 1901(b), states that payments should not be made for items or services furnished “by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual who is excluded when the person furnishing such item or service knew or had reason to know of the exclusion. ” The regulation’s language makes no reference to services or items provided by employees or contractors, so one could reasonably understand the payment prohibition to be relatively narrow. Reasonable or not, the OIG takes the opposite view and interprets the prohibition... --- - Published: 2015-04-17 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/false-claims-settlement-lapsed-license/ - Categories: Medicare Enforcement - Tags: Lapsed, Lapsed License, License I. Hospital Employed Therapist with Lapsed License The Department of Justice (DOJ) entered into a settlement with a nonprofit Michigan hospital this week resolving allegations that the hospital submitted false Medicaid claims.  The services had allegedly been rendered by a therapist with a lapsed license. Further, in an unusual move, DOJ required the hospital to acknowledge in the false claims settlement that it should have known of the lapsed license when it submitted the claims. II. No Difference Between a Lapsed License and an Exclusion for False Claims Liability This case is of particular interest because when analyzing the potential for False Claims Act liability, there is no appreciable difference between a person with a lapsed license and a person that has been excluded from Medicare or Medicaid. That is, the claims are said to be legally “false” because of the individual’s status (having no license and being excluded). Unless an employer can come up with a satisfactory explanation (in the eyes of DOJ or HHS/OIG) why he or she wasn't aware, that employer will either be presumed to have “known” of the status or it can be determined that he or she “should have known” of it. Of course, in either event, liability can attach! So, beware and be sure to screen your employees, vendors and contractors as required! Are you taking the necessary precautions to ensure you are not working with an excluded entity? We know it can be difficult to screen every Federal and State exclusion list. Call Exclusion Screening at 1-800-294-0952 or fill out the form below to hear about our cost-effective... --- - Published: 2015-04-14 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/false-claim-contractor-dental-providers/ - Categories: Medicare Enforcement - Tags: Contract Screening, Contrator, Screening I. Fraud Found in HHS' Backyard A Virginia contractor for dental providers was recently indicted by a grand jury on charges of wire fraud, health care fraud, identity theft and making false statements relating to health care matters. The contractor’s company provided administrative and consulting services to dental practices in and around the Washington, D. C. area. She faces ten years in prison for each count of health care fraud and five years in prison for each count of making a false claim regarding health care matters. The contractor faces several more years for all other charges against her.   The contractor allegedly used her company as a way to gain admission to dental practices in order to steal identities from patients and the dentists themselves. She would then use the stolen identities to create merchant accounts with dental financing programs by sending in several false enrollment applications. With these accounts, the contractor billed patients for inflated and unauthorized charges. The contractor went so far as to submit false charge slips bearing fake patient signatures for services that were never rendered. To support these false claims, the contractor created false patient records. II. False Claim This particular provider may be convicted of submitting false claims to Federal or State health care programs. This underscores why screening contractors and vendors is essential to running a fully compliant practice.  Any individual or entity that is convicted for submitting a false claim or committing health care fraud can be automatically excluded from receiving funds from... --- - Published: 2015-03-18 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-exclusion-cases-target-nursing-homes/ - Categories: Medicare Enforcement - Tags: Action, Exclusion, Home, Nursing, Nursing Home Exclusion Actin I. OIG Targets Nursing Homes Last year almost half of the exclusion violation matters reported by the Office of the Inspector General (OIG) involved nursing homes and rehabilitation facilities. This trend is continuing. Last month, the OIG reported five new cases on its website. Three of the five involved nursing homes. A fourth involved a non-profit school providing short-term stabilization and residential services to people overcoming emotional, behavioral or developmental challenges. It is impossible to say at this point what factors have led to the high percentage of cases involving facilities that provide some form of residential care. However, it certainly seems clear at this point that facilities providing services of this nature are well advised to actively begin screening – or to find a third party who can help them do it – if they haven’t already done so. II. Cost of Violations Rising A final note on the early returns is that the cost of exclusion violations seems to be going up. Civil money penalties for the year 2015 were averaging about $170,000. 00 per matter. While this appears to compare with the year 2014's average, it largely exceeds it. It actually represents about a 50% increase above the average in 2014, if the two large settlements from that year were factored out. Are you adequately screening for exclusions? We know it can be hard. Call Exclusion Screening at 1-800-294-0952 or fill out the form below for a free quote and assessment of your Exclusion Screening needs.   hbspt. forms. create({ portalId: "4660270", formId: "37f27296-30f9-41f4-b30e-af563534fea8", region:... --- - Published: 2015-02-19 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/excluded-podiatrist-racketeering-health-care-fraud/ - Categories: Medicare Enforcement - Tags: Action, Exclusion, Podiatrist, Podiatrist Exclusion Action I. Excluded Podiatrist Commits Health Care Fraud A Michigan podiatrist who was excluded from participation in the Federal health care programs for a period of 25 years allegedly entered into a health care fraud scheme with another Michigan doctor to perform podiatric services at his clinic.  The excluded podiatrist, whose license was also revoked, practiced podiatry at the clinic and occasionally presented himself to patients as the non-excluded doctor.  The physicians billed the government and private insurance for the services as if the non-excluded doctor performed the podiatric services. The Michigan Attorney General filed multiple charges against the excluded provider. These charges included: one count of Racketeering, a 20-year felony carrying up to a $100,000 fine; one count of Unauthorized Practice of a Health Profession, a 4-year felony with up to a $5,000 fine; thirteen counts of Health Care Fraud, a 4-year felony carrying up to a $50,000 fine; and five counts of Medicaid Fraud, a 4-year felony with up to a $50,000 fine.  Charges were also filed against the non-excluded provider, which included: one count of Racketeering; thirteen counts of Health Care Fraud; and five counts of Medicaid Fraud. The charges against the non-excluded provider carried the same felony consequences and fines. The facts released by the Michigan Attorney General do not indicate whether the non-excluded provider “knew” that the podiatrist’s license had been revoked or that he was excluded from participation in the Federal health care programs.  Whether he had affirmative knowledge, however, is irrelevant under the “knew or should have... --- - Published: 2015-02-13 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-issues-advisory-opinion-exclusions/ - Categories: Effect Of An Exclusion - Tags: Advisory, Advisory Opinion On Exclusions, Exclusions, Opinion I. Advisory Opinion on Payments for Services Provided Prior to Exclusion The Department of Health and Human Services Office of the Inspector General (OIG) issued an advisory opinion in response to payments received by an excluded provider for services performed prior to the effective date of his or her exclusion. The individual entered a criminal plea and a civil settlement to resolve various False Claims Act health care fraud allegations. As a result, the individual was excluded from participation in the Federal health care programs for twenty years. The individual was also required to sell his or her Practice to an unnamed Buyer. The sale took place on October 31, 2013. Before the individual was excluded, the individual and his or her practice performed services and submitted claims for these services to the Federal health care programs. However, the Federal health care programs made payments for these services after the individual’s exclusion date. The Buyer was in control of the Practice’s bank account at the time the payments were received. Under an agreement, the Buyer paid the monies received from the Federal health care programs to the excluded individual for the services. II. Exception to the Rule Under Section 1128 of the Social Security Act, payment may not be made by any Federal health care program for any items or services furnished directly or indirectly by an excluded individual. In this specific case, OIG distinguished the individual’s situation because the services were provided before the effective date of the exclusion. Therefore, receiving payment from the Buyer for these services after the exclusion date did not violate the terms of the individual’s... --- - Published: 2015-01-29 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/2014-review-oig-enforcement-actions/ - Categories: Medicare Enforcement - Tags: 2014, 2014 Actions Exclusion, Actions, Exclusion I. CMPs doubled in OIG Exclusion Violations 2014 Exclusion Screening, LLCSM dedicates a significant amount of time to examining the Office of the Inspector General’s (OIG) enforcement actions as they relate to exclusion violations.  As a broad overview, in 2014 HHS-OIG imposed $10. 54 million in Civil Monetary Penalties (CMPs) on providers that “knew or should have known” one or more of their employees or vendors was excluded from participation in the Federal health care programs.  Most noteworthy, this number more than triples the $3. 26 million in CMPs collected in 2013 and is the highest amount collected in the last five years. In 2014, the OIG cracked down on many different types of providers. The OIG's focus varied from pediatricians to large hospitals to home health organizations.  However, the OIG specifically targeted nursing homes, which totaled a quarter of all exclusion enforcement actions in 2014.  While nursing homes were also the most highly targeted industry in 2013, the OIG doubled the number of enforcement actions against nursing homes for exclusion violations in 2014. II. 2015 Likely to See Increase in OIG Enforcement Action Do these higher CMP amounts and increased enforcement actions mean there were simply more bad actors in 2014 than 2013? Likely no. These increases indicate that the OIG has identified an area ripe with exclusion violations and chose to target this sector. In fact, in its 2015 Work Plan, the OIG specifically mentions that fraud is prevalent in home health agencies and pledged to determine the extent to which home health agencies are... --- - Published: 2015-01-28 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/oig-report/ - Categories: Medicare Enforcement - Tags: Action, Dermatologist, Dermatologist Exclusion Action, Exclusion I. OIG Report In the Office of the Inspector General's (OIG) semiannual report to Congress, it claimed credit for excluding 2,297 individuals and entities from Medicare, Medicaid, and other Federal health care programs. The OIG also claimed credit for initiating 506 criminal and 267 civil actions.  According to the OIG report, most of the exclusions resulted from convictions for crimes relating to Medicare or Medicaid, patient abuse or neglect, or license revocations. The civil and criminal actions were primarily initiated against “individuals or entities engaged in health-care related offenses. ” In addition, the OIG told Congress that it was responsible for generating $1. 26 billion in investigative receivables due to the Department of Health and Human Services. II. Failure to Screen The OIG also identified some of the cases that were felt to be important. Two of these cases involved exclusion related issues. In one case, the OIG imposed $15,000 in penalties against a company under a corporate integrity agreement for failing to timely screen employees and other “covered persons. ” This is of particular interest to us because the penalty was not imposed for having an excluded employee.  Instead, the penalty was imposed for failing to screen!  This, again, demonstrates the interest and concerns of the OIG in exclusion issues. III. Mandatory Exclusion In the other case, a physician who had been excluded due to a conviction for a health care related offense, arranged an elaborate scheme to hide his involvement in a dermatology practice so that it could bill Medicare and Medicaid... --- - Published: 2015-01-21 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/student-loan-default-becoming-top-reason-exclusion/ - Categories: Effect Of An Exclusion - Tags: Action, Default, Exclusion, Loan, Student, Student Loan Default Exclusion Action Providers are often surprised to learn that a person can be excluded from participation in federal health care programs because of student loan default.  In fact, the failure to repay student loans is one of the most common reasons people find themselves on an exclusion list. 1  I. Federal Regulations Surrounding Student Loan Default & Exclusions The Office of the Inspector General (OIG) makes it clear that if a provider fails to repay a Health Education Assistance Loan (HEAL), he or she can be excluded. The federal government, however, has not issued any new HEALs since 1998. 2 Coincidentally, most providers who received Health Education and Assistance Loans between 1978 and 1998 are still practicing today.  As of April 20, 2014, 846 HEAL borrowers were in default. Therefore, they were all excluded from the Federal health care programs.  Together, these 846 borrowers owed over $1. 4 million to the federal government.  Indeed, some HEAL borrowers had been in default since 1980. 3 The OIG has permissive authority to exclude providers that have defaulted on student loans backed by the U. S. Department of Health and Human Services (HHS). 4 The minimum exclusion period is until the default has been cured, or until the provider and the Public Health Service reach a satisfactory resolution. 5 In addition, the OIG has proposed to amend their regulations to not only exclude people who default on Heath Education Assistance Loans, but also people who default on loan repayment program (LRP) obligations, such as those administered by the Indian Health Service... --- - Published: 2015-01-19 - Modified: 2025-08-14 - URL: https://exclusionscreening.com/screen-every-state-exclusion-list/ - Categories: Exclusion Screening Basics, Medicare Enforcement - Tags: Exclusion, Lists, Screening, Screening State Exclusion Lists, State The Office of the Inspector General (OIG) issued a Special Advisory Bulletin in May 2013, which states that providers can “avoid potential Civil Monetary Penalty (CMP) liability” simply by checking the List of Excluded Individuals and Entities (LEIE) to “determine the exclusion status of current employees and contractors. ” This past fall, September – November 2014, OIG collected $1. 54 Million in Civil Money Penalties (CMPs) in cases involving the employment of persons who have been “excluded” from Medicare. These providers were held liable because they “knew or should have known” that an employee or contractor was excluded from participation in the Federal health care programs. The “knew or should have known” standard arises from the same 2013 OIG Special Advisory Bulletin. OIG states that because the LEIE is updated monthly, OIG recommends that providers check their employees and vendors against the LEIE and SAM monthly in order to avoid CMP liability. The CMPs a provider may face for employing or contracting with an excluded individual or entity include liabilities of $10,000 for each item or service furnished directly or indirectly by an excluded individual, in addition to an assessment of up to three times the total damages, and exclusion from participation in the Federal health care programs. In addition to the federal lists, forty-one states now have their own state exclusion list. These states require, at a minimum, that providers check their employees and contractors against their state exclusion list in addition to the LEIE as a requirement to participate in... --- - Published: 2015-01-02 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-exclusion-screening-list/ - Categories: Exclusion Screening Basics - Tags: Action, Exclusion, Oig, Scope, Scope Of Oig Exclusion Action I. Federal and State Agencies Conducting Audits As many healthcare providers and suppliers have painfully learned over the last year, federal and state law enforcement agencies, along with many of the contractors with whom they work, are actively conducting audits of Medicare and Medicaid claims submitted to the government for coverage and payment One of the least understood mandatory obligations applicable to virtually every healthcare provider and supplier who accepts Medicare or Medicaid is the requirement that all participating providers are REQUIRED to screen more than just their staff.  Instead, they must also screen contractors, vendors, and agents to ensure that they and their employees have not been excluded from participation in federal and state healthcare programs.  The fact that these individuals and entities must be screened through literally dozens of federal and state exclusion databases further complicates this mandate.   II. Broad Scope of OIG Exclusion Action Importantly, the scope of an exclusion action is extremely broad. The Department of Health and Human Services, Office of Inspector General (HHS-OIG) has taken the position that if a vendor, contractor or supplier of administrative, management or support services has been excluded from participating in the Medicare or Medicaid programs, they are effectively barred from working with most health care provider and supplier entities.  As HHS-OIG writes: "Excluded persons are prohibited from furnishing administrative and management services that are payable by the Federal health care programs. This prohibition applies even if the administrative and management services are not separately billable. For example, an excluded individual... --- - Published: 2014-12-17 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-enforcement-civil-monetary-penalties/ - Categories: Medicare Enforcement - Tags: 2014, 2014 Exclusion Enforcement Focus, Enforcement, Exclusion, Focus I. Civil Monetary Penalties Twenty-five out of the fifty-five exclusion enforcement actions reported in 2014 have occurred in home health, hospice, or nursing and rehabilitation facilities. The Civil Monetary Penalties (CMPs) imposed in these cases range from $10,000 to $428,935 for employing just one individual that the employer knew or should have known was excluded from participating in the Federal health care programs. Providers are reminded that the Office of the Inspector General (OIG) recommends screening employees and vendors before hiring or contracting with them, and to continue screening on a monthly basis. One reason why some providers were liable for much higher CMPs is due to the amount of time the provider employed or contracted with the excluded individual before disclosing the violation to OIG. The government cannot pay for any services provided directly or indirectly by an excluded person. Therefore, the entire amount must be repaid back to the government. This amount is typically subject to a minimum multiplier of 1. 5 times the total amount paid by the Federal health care programs. For that reason, the longer you employ a person without realizing they are excluded, the more you will be liable to pay back to the Federal health care programs. Here is a list of enforcement actions against home health, hospice and nursing facilities in 2014: 2014 OIG Enforcement Action You can view the entire list on the OIG's Enforcement Action Page here. II. Home Health Agencies Vulnerable to Fraud OIG conducted a study in late... --- - Published: 2014-12-02 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/proper-exclusion-screening-process/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Exclusion Screening Process, Process, Screening At Exclusion Screening, LLCSM, we know the ins-and-outs of the exclusion screening process. In our opinion, an effective screening process requires some mandatory tools. To ensure that there are no holes in your screening process make sure you have: A List of Employees and Vendors All providers need a complete list of employees and vendors. Your Exclusion Experts here at Exclusion Screening, LLCSM will ensure that you aren’t missing any vendor that may present a liability. We know that it may be difficult to think of every possible contractor that directly or indirectly furnishes an item or service that is payable by the Federal health care programs. That’s why we guide our clients through the list making process. If you choose to do your own screening, you must ensure that you have the following pieces of information for all employees and contractors: full name, maiden name, date of birth, address and Social Security Number. Access to Exclusion Lists Providers who perform their own screening will need to have the ability to access the online state and federal databases. At a minimum, providers should check their employee and vendor lists against the OIG-LEIE, GSA-SAM, and the 41 state Medicaid Exclusion Lists. Time and Ability for Exclusion Screening Finding time for monthly checks may be difficult, but it is critical. Employing one excluded person can cost a provider tens of thousands of dollars. Proper exclusion screening is going to take a decent chunk of one employee’s time. If you do not have a... --- - Published: 2014-11-24 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/administrative-process-oig-exclusions/ - Categories: Exclusion Screening Basics, Medicare Enforcement - Tags: Enforcement, Exclusion, Oig, Oig Exclusion Enforcement Process, Process I. Mandatory OIG Exclusions When the Office of Inspector General (OIG) considers imposing a mandatory exclusion, it sends the individual or entity a Notice of Intent to Exclude.  The Notice includes the reason for the proposed exclusion and the possible effect of an exclusion. It also gives the individual or entity 30 days to respond in writing with information and evidence that he or she wants the OIG to consider in making its final decision. The OIG will almost always decide to impose a mandatory exclusion. The individual or entity is then sent a Notice of Exclusion that includes his or her appeal rights. The exclusion goes into effect 20 days after the Notice of Exclusion is mailed and notice to the public is provided on the OIG website. The OIG’s decision to exclude can be appealed to an U. S. Department of Health and Human Services (HHS) Administrative Law Judge (ALJ). Adverse decisions by an ALJ can then be appealed to the HHS Departmental Appeals Board (DAB). Individuals may also seek judicial review of any final decision by the DAB. II. Imposing OIG Exclusions There are actually four different administrative processes for permissive exclusions and all of them differ from the process detailed above. As described below, the process utilized for permissive exclusions is dependent on the reason for the exclusion. OIG may consider imposing a permissive exclusion for submitting claims for excessive charges, unnecessary services, services which fail to meet professionally recognized standards of health care, or the failure of an... --- - Published: 2014-11-20 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/cmp-liabilities-much-higher-others/ - Categories: Medicare Enforcement - Tags: Cmp, Cmp Liabilities, Liabilities A quick review of the Office of Inspector General's (OIG) exclusion enforcement actions might make one wonder why the Civil Monetary Penalties (CMPs) for some entities are only $10,000 while others are closer to $2,000,000. We were curious as well, and took a look into the factors that might contribute to the vast differences in money owed. Why CMP Liabilities are Higher than others The easiest answer is that CMPs tend to be lower for entities that self-disclosed the exclusion violation as opposed to entities that were subject to an OIG investigation. “Tend” is the key word here. You’ll notice that the August 5, 2014 case (see "CMP Liabilities Higher" link above) was self-disclosed and has the highest CMP amount listed at $1,983,907. 51. I. CMP Liability Depends on How Many Excluded Individuals Are Hired Another contributing factor is the number of excluded individuals that the provider employed or contracted with. More individuals means that more claims were likely submitted for payment. Therefore, the government likely paid more money to these providers than providers who only employed or contracted with one excluded person. This is evident in the two exclusion actions which took place on August 5, 2014. The University Hospital employed one excluded individual and owed $10,000 in CMP liabilities, while the laboratory owed nearly $2,000,000 because it knew or should have known that four employees were excluded from participation in the federal health care programs. However, it's important to note that the March 7, 2014 case which totaled... --- - Published: 2014-11-20 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/monthly-screening/ - Categories: Exclusion Screening Basics - Tags: Exclusion, Exclusion Screening Obligations, Obligations, Screening I. OIG Recommends Monthly Screening While there is not a formal regulation that mandates monthly exclusion screening, OIG issued guidance in May 2013, which recommended that providers check their employees and contractors against the OIG-LEIE each month because the LEIE is updated on a monthly basis. Just how many new names could possibly be added to the LEIE each month? According to Modern Healthcare, OIG adds approximately 300 new names to the LEIE every month. Providers are reminded that if OIG discovers that a provider billed for items or services provided by an excluded individual, it may impose CMPs up to $10,000 for each item or service billed to the Federal health care programs. So, while it is not necessarily mandatory at the Federal level, monthly screening is in every provider’s best interest, especially with such a large number of names being added to the LEIE each month. II. 14 States Require Monthly Screening Furthermore, monthly screening IS mandatory in at least fourteen states, while many others strongly suggest providers screen employees and vendors against their state list and the LEIE monthly. For example, Hawaii states on its Medicaid website that any provider who participates in the Medicaid program must search Hawaii’s excluded provider list monthly and the LEIE on an annual basis to determine whether an employee or contractor has been excluded from participation in the Medicaid program. Kentucky mandates monthly screening against Kentucky’s state Medicaid list, the OIG-LEIE, and the GSA-SAM. New Jersey made exclusion searches mandatory in... --- - Published: 2014-11-17 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/alert-florida-excluded-providers/ - Categories: Medicaid Enforcement - Tags: Actions, Exclusion, Florida, Florida Medicaid Exclusion Actions, Medicaid I. Florida's State Exclusion. Excluded Providers Costs OIG Over 2. 7 Million The Office of the Inspector General (OIG) recently released a study on a subset of Florida’s Medicaid payments for pharmaceutical items. The study showed that in 2009 and 2010 the State agency made $180,000 in payments for pharmaceutical items prescribed by excluded providers. OIG, comparing this number to the total number of pharmacy payments, concluded that the State agency may have paid up to $2. 7 million for items that excluded providers had prescribed. OIG concluded that these over-payments occurred because the State agency did not have proper policies in place to conduct prepayment review. Specifically, the agency had not established sufficient prepayment controls to ensure that valid provider IDs were on every pharmacy claim, and that the prescribing provider identification numbers were valid before making payments. II. Monthly Exclusion Screening Is Essential to Maintaining Effective Compliance Programs Furthermore, the State agency was only conducting periodic searches of the LEIE and the GSA-SAM, which are maintained by OIG and CMS, respectively. This serves as just another reminder to providers that exclusion searches, in order to be effective, must be conducted monthly and must include searches of the LEIE, the GSA-SAM, and all 41 state Medicaid lists. Failure to search every list creates a hole in your screening process and allows excluded individuals to continue billing to the Federal health care programs. Florida has since created its own suspended provider list like a majority of the states. In addition to building... --- - Published: 2014-11-12 - Modified: 2025-08-25 - URL: https://exclusionscreening.com/cms-exclusion-information-sharing/ - Categories: Medicaid Enforcement - Tags: Actions, Exclusion, Medicaid, State I. Take It from CMS: If You're Excluded in One State, You're Excluded in All States Section 6401(b)(2) of the Affordable Care Act (ACA) required the Centers for Medicare and Medicaid Services (CMS) to create a national database where State agencies could share and access information about individuals and entities that were terminated from the Medicare, Medicaid, or CHIP programs.  This platform would help states comply with ACA section 6501, which mandates that a provider must be terminated in all state Medicaid programs if he or she were terminated “for cause” in one state. CMS created the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS) to make this exclusion information available to all State Medicaid agencies. Under section 6401(b)(2), states were asked to submit the terminated provider’s name, National Provider Identifier (NPI), and other identifying information to MCSIS. This information was incorporated into MCSIS so that other states could identify providers that needed to be terminated. Even though CMS has the authority to require states to submit this information, it has only asked states to comply. CMS’ failure to make reporting mandatory resulted in a very deficient database. II. CMS' Comprehensive List... Not So Comprehensive Only thirty-three states submitted information to CMS and many of the records were incomplete. For example, CMS asked states to only submit providers that were terminated “for cause,” but over 2,000 records lacked a “for cause” termination. In addition, 59 percent of the records also did not include provider NPIs, which the ACA... --- - Published: 2014-11-12 - Modified: 2025-10-02 - URL: https://exclusionscreening.com/gary-cantrell-testimony/ - Categories: Medicare Enforcement - Tags: Gaps, Leie, Leil Gaps HHS/OIG Deputy Inspector General Gary Cantrell testified earlier this year that States are failing to report all of the adverse actions taken by their Licensing Boards. He suggested that the “manner and time of the notices” are unreliable. Cantrell attributed these concerns to the “voluntary” nature of State reporting obligations. I. The Impact on Exclusion Enforcement Gary Cantrell stressed the importance of the Office of the Inspector General's (OIG) ability to exclude individuals and entities from participating in federal health care programs as a key administrative tool in fighting fraud. He emphasized that “adverse actions... enable us to identify numerous individuals who are subject to exclusion... . ” If the OIG, however, is not informed about these individuals in the first instance, or is informed in an untimely way, then it may never become aware that they should be considered for inclusion on the List of Excluded Individuals and Entities (LEIE). This creates a significant risk to the Medicare Trust Fund and thwarts the OIG’s ongoing exclusion enforcement initiative. Mr. Cantrell stated that the issue arises principally due to the manner in which the information is reported. States report the adverse actions to the OIG on a voluntary basis. It can also be reported from individual State boards, general public notices of State board action, and from the working relationships between OIG exclusion analysts and other agencies. In addition to incomplete reporting, the timing and manner of the notices completely depend on each State’s licensing board. Cantrell recommended that Congress explore requiring more reliable... --- - Published: 2014-11-11 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/screening-exclusion-databases/ - Categories: Medicare Enforcement - Tags: Databases, Federal, Screening, Screening Federal And State Databases, State I. Which Exclusion Databases Do I Need to Screen? The Office of Inspector General (OIG) recommends that you screen your employees, contractors, and vendors every month against the List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM). Your State Medicaid director mandates monthly screening of your State exclusion databases, in addition to the LEIE and, perhaps, the SAM. In a number of states, when you enroll or re-enroll you have to certify that none of your employees or contractors are excluded from any Federal or State Healthcare Program.   If your State happens to be Texas, you will have to certify that you have conducted an “internal review” to determine if any of your employees or contractors have been excluded from Medicare, any State Healthcare program, or from the CHIP program. Unfortunately, each of the 40+ exclusion databases to be searched (the LEIE, SAM and 41 States) are “stand alone” exclusion databases that are unique in their composition, content and the way they can be screened. This article discusses those differences and the problems associated with the exclusion databases. II. Screening the LEIE The LEIE contains approximately 60,000 persons and is updated monthly. It contains identifying information such as the excluded individual’s name, date of birth, provider type, and other information. It is also searchable or downloadable. The LEIE allows a provider to perform a basic name search. It then provides a list of names that match your search. To determine if the potential match is... --- - Published: 2014-11-10 - Modified: 2025-08-26 - URL: https://exclusionscreening.com/2015-oig-work-plan/ - Categories: Medicare Enforcement - Tags: Federal, Federal Grants, Grants I. Concerns of the 2015 OIG Exclusion Work Plan The Office of Inspector General (OIG) expressed concern regarding exclusion and suspension enforcement in its 2015 OIG Work Plan. The OIG announced that its Office of Audit Services will study whether the operating divisions within its own agency have been taking adequate precautions to ensure that individuals and entities that have been suspended or debarred are not being awarded Federal grants or contracts. Noting that “Federal agencies are required to make awards only to responsible sources,” the 2015 OIG Work Plan states that precluding firms or individuals that have been excluded or suspended from receiving contracts or assistance is one of the ways of achieving that objective.  The Work Plan suggests it is following up on a Government Accountability Office (GAO) Report that “found that some agency programs need greater attention, and government wide oversight could be improved. ” II. OIG Agency Accountability  We must note, however, that the study seems only to include suspensions and debarments (which are temporary exclusions or exclusions for a fixed period of time) reported in the System for Award Management (SAM), the exclusion database maintained by the General Services Administration (GSA). While this might signify that OIG is satisfied with agency enforcement of its own administrative sanctions, the important takeaway is that OIG is holding its own agency to a standard that includes screening the SAM in addition to the LEIE.  III. Conclusion The inclusion of this study in the work plan has several important messages.... --- - Published: 2014-10-13 - Modified: 2025-08-13 - URL: https://exclusionscreening.com/oig-provider-self-disclosure-protocol/ - Categories: Effect Of An Exclusion - Tags: Oig, Protocol, Self Disclosure, Updated, Updated Oig Self Disclosure Protocol I. Provider Self-Disclosure Protocol: New Guidance Sheds Light on Disclosure On April 17, 2013, the Office of the Inspector General (OIG) issued an updated Provider Self-Disclosure Protocol that many viewed as an attempt to make the process somewhat more “user-friendly. ” Regardless of whether that was the aim – or if it was achieved to some extent – the reason the update is of particular interest to us is that it has a section that contains specific guidance on the disclosure of conduct involving excluded employees or contractors. The original protocol, however, was silent on the topic. By most measures, the OIG’s protocol for self-disclosure is still an onerous one. Providers are required to conduct an internal investigation and present their findings in the form of a detailed provider self-disclosure narrative. The narrative must include, among other things, a complete accounting of the investigation itself, the conduct involved, the corrective efforts taken, the damages incurred, and how that amount was determined. II. Additional Requirements In addition to these general requirements, disclosures relating to excluded employees or contractors has to include the following additional information: Who was excluded, their job duties and the dates of employment or contract The screening that was done before and/or during the employment or contract Why or how the screening process failed The corrective actions that have taken A calculation of the total amounts claimed and paid by Federal Program The revised protocol also requires that all other employees be screened through the OIG list of... --- --- > Contact Exclusion Screening LLC by email at support@exclusionscreening.com ---