Exclusion Checks.

Exclusions.

Automate exclusions from over 40 different sources including OIG/SAM. 

What is an exclusion?

An exclusion means that an individual or entity is excluded from receiving any money from federal or state healthcare programs. Healthcare exclusions apply to any items or services a provider may furnish, order, or prescribe. An exclusion can include an individual, organization (healthcare services, suppliers, consultants, etc.) or both. 

Will the exclusion and the payment prohibition continue to apply to an individual if he or she
changes from one healthcare profession to another?

The exclusion and the payment prohibition will continue to apply to an individual even if he or she changes from one healthcare profession to another, while excluded. The payment prohibition applies to all methods of Federal Healthcare Program Payments.

When will an individual or entity face a violation and/or penalties?

The excluded individual or entity may have provided support bunded into a cost for services and is not billed separately. The organization that uses these services and the excluded person would be in violation and subject to penalties. The existence of an excluded person or entity can be discovered through audits, algorithms, and whistleblower claims. 

Are immediate family members of excluded individuals excluded from participation in Federal Healthcare Programs?

Immediate family members of excluded individuals are also excluded from participation in Federal Healthcare Programs. An "immediate family member" includes the excluded person's: 

Do same-sex marriages meet the definition of an "immediate family member?"

Same-sex marriages meet the definition of "immediate family member" whether it being foreign or domestic, and the couple recognizes the marriage is under the law.

How will an individual/organization face penalties for hiring or contracting with Excluded Individuals and Entities?

Organizations that employee or contract with excluded individuals or entities are subject to civil monetary penalties (CMP). There are many additional costs which include defending claims, audit and records production, and loss of productivity (to name a few) during an OIG audit which can last for months or even years. 

What is the importance of exclusion monitoring?

It is the providers' (the organization billing for services) obligation to regularly check the OIG exclusion list to ensure that new hires and current employees are not on it. The list contains the name of excluded individuals or entities at the time of the exclusion, the provider type, the authority under which the indiviual was excluded, and the state where the excluded individual resided. Organizations are liable for their own employees and third-party vendors. Many states have issued state Medicaid bulletins that require monthly monitoring of the OIG LEIE, SAM, and their own State Medicaid lists. 

What does The Office of Inspector General (OIG) impose?

The OIG imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act. The OIG exclusion list is updated on a monthly basis, and if an individual or entity has been reinstated, they are removed from the list. 

Where can the effects of an exclusion be found?

The effects of exclusion are outlined in the updated Special Advisory Bulletin on the Effect of Exclusion from Participation in federal Health Programs but the primary effect is that no payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity.  

What does the List of Excluded Individuals and Entities (LEIE) contain?

The LEIE contains only the exclusion actions taken by OIG. Physicians and similar Providers can be found by the person's name or their National Provider Number (NPI). 

Who is excluded from a National Provider Number (NPI)?

Many individuals and entities that are excluded by OIG do not have NPIs to include in the LEIE. For those individuals and entities that have NPIs, OIG has added that information to records starting in 2008 and has included NPIs in the LEIE since that time.

When will a search result not be available in the OIG?

Suppose a search result does not contain a DOB (date of birth), UPIN (unique physician identification number), NPI (national provider identifier), SSN (social security number), or EIN (employer identification number). In that case, it is not available from OIG.

How can I obtain a copy of an individual or entity exclusion notice?

To obtain a copy of an individuals or entity exclusion notice, you must submit a written notice via email or fax with a screenshot or attachment from the LEIE identifying the individual or entity. Requests without a screenshot or attachment from the LEIE will be insufficient. If the subject has been reinstated, the reinstatement notice may be available. 

What is the System for Award Management (SAM)?

The System for Award Management (SAM.gov) is an official website of the U.S. Government. There is no cost to use SAM.gov.
Today, you can use this site to:


What if an individual's name appears on the SAM list?

If an individual's name appears on the SAM list, you need a DUNS Number or Cage Code. The primary identifier is the company name. If you have a name that is excluded, but you do not have their DUNS number or CAGE Code, you will need to contact the SAM customer service desk. The agency points of contact are available by navigating the SAM Help tab then click the exclusions information, then Agency Exclusion POCs.