Exclusion Checks.

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. 

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.

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. 

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

• Husband/Wife

• Natural or Adoptive Parent,

• Child, or Sibling

• Step-parent, Step-brother/Step-Sister

• Father-in-law, Mother-in-law, Daughter-in-law, Son-in-law or Sister-in-law,

• Grandparent or Grandchild

• Spouse of a grandparent or grandchild 

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.

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. 

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. 

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. 

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.  

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). 

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.

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.

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. 

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:

• Register to do business with the U.S. Government

• Update, renew, or check the status of your entity registration

• Get a Unique Entity ID

• Search for entity registration and exclusion records

• Search for assistance listings (formerly CFDA.gov), wage determinations (formerly WDOL.gov), and contract opportunities (formerly FBO.gov)

• Run contract data reports (formerly part of FPDS.gov).

• View and submit BioPreferred and Service Contract Reports

• Access publicly available data via data extracts and system accounts

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.