Exclusion screening for medical billing companies

Why medical billing companies are exposed

• Your work is part of the claim. Federal programs can’t pay for items or services furnished by an excluded person, and “furnished” includes administrative and support work, billed separately or bundled. A coder who assigns the codes or a biller who submits the claim is in that chain.
• The penalty for contracting with an excluded party lands on your client. OIG’s Civil Monetary Penalties Law includes a separate penalty, up to $24,947 per violation, for arranging or contracting with an excluded person. When an excluded person does a client’s billing, the client carries the overpayment and possibly this penalty, and it will look to you.
• One excluded employee touches many clients. A biller working five client queues creates five overpayments and five separate disclosure decisions.
• Credentialing clients expect you to catch it. If you enroll providers for clients, they assume you checked exclusion status. A check at enrollment won’t catch a provider excluded eight months later.

Who to screen

• Coders, billers, charge entry staff, and claims submitters
• Accounts receivable, denial management, and payment posting staff
• Credentialing and enrollment specialists
• Client account managers and anyone with access to a client’s practice management system
• Subcontractors, overflow coding vendors, and independent contractors who work your queues
• Owners, officers, and managing employees of the billing company

The group billing companies forget most often is subcontracted and overflow coders. The client sees them as your people, but they often aren’t on your HR roster.

“You guys did a great job! The new system looks great and was easy to navigate and upload!!! The process was a lot quicker so I appreciate all the new features.”

Lisa Robinson, Chief Operating Officer, Healthcare Compliance Network

About 1,000 healthcare organizations trust us with their screening every month, including many medical billing companies and RCM firms. Exclusion Screening was founded by former federal prosecutors Paul Weidenfeld and Robert Liles, and we are a partner of the American Medical Billing Association.

How we handle medical billing screening

• Monthly screening of your whole team against the OIG LEIE, SAM, and all state Medicaid exclusion lists: employees, subcontracted and offshore coders, and owners.
• Identity verification before anything is flagged. We confirm identity with Social Security number, date of birth, NPI, or license data, so a common name doesn’t turn into a false alarm.
• Our specialists resolve matches. When a name comes back, one of our trained specialists works it to a conclusion.
• Dated records for every person, every month, so you can show a client that everyone working its account was screened.

Add screening to the services you sell

You aren’t required to screen your clients’ staff. Your clients are, and most of them would rather hand it off. Offering it adds a recurring line of revenue from clients you already serve.

• White-label. Screening goes out under your brand.
• One roster per client, with its own dated records, ready for that client’s auditor or payer.
• Our specialists resolve matches, so you never send a client a false alarm about one of its physicians.

Plans start at $30 a month for up to 100 people, with custom pricing for billing companies that resell screening to clients. See pricing or schedule a demo.

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What the rules require of medical billing companies

The rules were written for providers, so most of a billing company’s obligations reach it through its clients.

The claims your clients submit. An organization that submits claims for items or services furnished by an excluded person is liable if it “knew or should have known” the person was excluded. Because “furnished” includes administrative work behind a claim, an excluded coder or biller can taint a client’s claims.

The contracts your clients sign. A separate CMP covers arranging or contracting with an excluded person, up to $24,947 per violation. If your company, an owner, or an employee doing the client’s work is excluded, the client may face this penalty on top of the overpayment.

Your own direct exposure. Whether OIG can penalize a billing company itself for presenting or causing claims tied to an excluded employee depends on the facts of the arrangement. Your contract is the more immediate risk. Read your client agreements for any representation that your staff are not excluded and for indemnification clauses, since those decide who pays first.

More in screening contractors and vendors and our legal guide to OIG exclusions.

What it costs when screening fails

We found no 2020–2025 OIG settlement against a billing or RCM company for an excluded employee. The settlements land on providers, and two show that non-clinical work counts:

• In 2023, Heaven Sent Helpers (South Carolina) paid $115,381. OIG said the excluded person furnished items or services billed to federal programs, “including administrative and management services” (OIG).
• In 2024, Independence Home Healthcare (California) paid $377,774 and accepted a 20-year exclusion. The excluded person was an office manager. That settlement also resolved improper remuneration allegations (OIG).

Both people were the provider’s own employees. When your employee does the same work under contract, the client’s exposure runs through the contracting penalty.

The bill has two parts: a CMP of up to $24,947 per item or service, plus repayment of every affected claim. For non-billing staff, OIG’s self-disclosure guidance uses a proxy of salary and benefits times the federal payer mix. How that proxy applies to a vendor’s employee spread across several clients is a question for counsel.

Under OIG’s Self-Disclosure Protocol, settlements generally start at a 1.5x multiplier on the overpayment. If the government finds it first, the False Claims Act allows up to treble damages. The client makes the disclosure decision, so you want to find the problem before it does. Past amounts are in historical OIG settlements and penalties.

Common medical billing screening mistakes

1. Skipping your own staff. Your coders and billers are the screening you’re responsible for. If you also resell screening to clients, don’t let those rosters crowd out your own.
2. Treating credentialing as the screen. An exclusion check at enrollment covers one day.
3. Leaving out offshore or subcontracted coders. If a person works your client queues, they belong on your roster, whoever pays them.
4. Federal lists only. A person excluded only by a state Medicaid program won’t appear on the OIG list, and if a client bills that state’s Medicaid, the gap is the client’s liability. See why to screen every state list.
5. Sending clients unresolved name matches. Confirm identity before you tell a client one of its physicians might be excluded.

A screening program for a medical billing company

1. Build your own roster. Include every employee, contractor, subcontractor, and owner who touches client claims or client systems.
2. Screen before system access. Check the federal lists and the Medicaid lists of every state where your clients bill before anyone gets a login.
3. Re-screen monthly. Run your own staff every month, and any client rosters you screen as a service on the same cycle.
4. Set a client notification rule. Decide in writing how fast you tell a client about a confirmed match, and put it in your service agreement.
5. Keep dated records. Store per-person results by month so you can show any client that the people on its account were screened.
6. Plan for a hit on your own staff. Pull the person from client work, map every account they touched, and call counsel before you notify clients.

More on structure: building a compliance program and who must be screened.

Questions billing company compliance teams ask

Our coders never treat patients. Do they really need screening?
Yes. Federal programs can’t pay for items or services furnished by an excluded person, and that includes administrative and support work behind a claim. If a coder working a client’s Medicare claims is excluded, those claims can become overpayments, and the client can face a penalty for contracting with an excluded party.

Can we offer exclusion screening to our clients?
Yes. You aren’t required to screen your clients’ staff, but they are, and many would rather buy it from the billing company they already trust. We white-label the service so it goes out under your brand, set up each client as its own roster with dated records, and our specialists resolve matches before you report results. You add a recurring line of revenue without building a screening operation of your own.

Isn’t checking exclusions part of credentialing already?
Only at a single point in time. People are added to exclusion lists every month, so a provider who cleared enrollment can be excluded later and keep generating claims. Credentialing confirms someone at the start. Monthly screening catches what changes after.

What happens to our clients if one of our billers turns out to be excluded?
Each client whose claims that biller worked has a potential overpayment and its own self-disclosure decision. Remove the person from client work immediately, map every account and date they touched, check your agreements’ notice terms, and talk to counsel before you send notices. See what to do with a confirmed exclusion.

If you bill for home health clients, see exclusion screening for home health agencies.

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See SAFER Plus screen your billing team, and how you can resell screening to your clients under your brand. Schedule a demo →