Check Excluded Provider Lists for Both Clinical and Administrative Employees

Utilizing Excluded Providers is forbidden and can invoke significant penalties.

It is important to regularly check your employees and subcontractors against the OIG’s List of Excluded Individuals/Entities (LEIE) and other exclusions databases. Health care providers who hire or contract with an individual on the LEIE may be subject to civil monetary penalties (“CMP”) if they submit claims to a Federal health care program for items or services provided, directly or indirectly, by excluded individuals.

Many providers mistakenly think they only need to check clinicians against the excluded provider databases, when in fact, they may need to check every employee and subcontractor.  The prohibition includes anyone involved in direct patient care, indirect patient care, administrative and management services, as well as items or services furnished at the medical direction or on the prescription of an excluded person when the person furnishing the services either knows or should know of the exclusion.

In its 2013 Special Advisory Bulletin, HHS gave updated guidance on how to comply with this regulation.

How to Determine Whether a Person or Entity Is an Excluded Provider

Exclusion List Check Best Practices

  1. Check the LEIE monthly. While not required, HHS recommends checking personnel rosters, including temporary staff working under staffing company contracts, against the LEIE exclusion list once a month, as it is updated monthly.
    1. It would be best practice to print out screen shots or otherwise document proof that the list was checked, as companies that violate the exclusion rules can have their Medicare payments taken back, plus fines of $10,000 per claim, if anyone involved in the care was excluded.
  2. When verifying individuals and entities using the LEIE and other exclusion databases, use a very broad search to assure you don’t miss anyone.
    1. Search with first initial only.
    2. Request and search all previous last names (such as maiden name).
    3. If you’ve conducted a pre-employment background check, use this to identify additional names to search.
    4. Search variations of commonly altered names (such as Jim for James).
  3. Search all available exclusion databases prior to hire.
    1. In addition to the LEIE, providers should check available State Medicaid Exclusion Databases. Ideally, all federal and state exclusion lists should be checked, because a provider excluded in one state is excluded in all states.
    2. Other possible databases to check include the National Practitioner Data Bank, the Health Care Integrity and Protection Databank, and the General Services Administration’s (GSA) Excluded Parties List System (EPLS) and System for Award Management (SAM).
  4. Be cautious with contracted entities and services.
    1. When using a contracted provider, either get written assurance that the entity is checking the LEIE, or check the provider yourself.
    2. While a provider may hire another entity for exclusion database monitoring services, the provider is ultimately responsible for compliance.

Exclusion List Helpful Hints

  • If you have only a few names to search, consider using the LEIE Online Searchable Database. It allows you to search up to five names at one time and to verify identities using a Social Security number or date of birth.
  • If you have a large group of individuals to search, consider downloading the entire list via the LEIE Downloadable Database to your computer and using a spreadsheet or database program to perform searches.
  • If you think an employee may be on the excluded parties list, request the employee to provide a letter of proof from the OIG or the state Medicaid agency documenting that there is no exclusion.
  • If you receive a positive match, check the Special Advisory Bulletin on the Effect of an Exclusion for guidance. If you have already employed the individual, check the Self-Disclosure Protocol.

Update Your Corporate Compliance Plan to Include Exclusion List Checks

Your corporate compliance plan should include policies on checking OIG and state maintained exclusion lists prior to hire and on an ongoing basis, as well as the procedures to follow while checking the exclusion lists.

Additional Resources for Information about Excluded Providers:

  1. Health and Human Services. This Web site, hosted by the Office of the Inspector General within the federal Department of Health and Human Services (HHS), outlines their exclusion program and includes a searchable version of their List of Excluded Individuals/Entities (LEIE).
  2. Government Services Administration. This Web site is provided as a public service by the Government Services Administration for the purpose of efficiently and conveniently disseminating information on parties that are excluded from receiving federal contracts, certain subcontracts, and certain federal financial and non-financial assistance and benefits, called the System for Award Management (SAM).
  3. Missouri Medicaid Audit & Compliance (MMAC) list of terminated providers.
  4. Illinois Department of Healthcare and Family Services (HFS) Office of Inspector General (OIG) list of excluded providers.

Article was originally published in the LHE Monitor.