5 Things Healthcare Organizations Should Know About Exclusions

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Healthcare exclusions can be costly for healthcare organizations. The Department of Health and Human Services (DHHS) Office of Inspector General (OIG) has authority to implement exclusions and exclude providers from participating in federal healthcare programs such as Medicare and Medicaid. If your healthcare organization engages excluded individuals or entities, you could be liable for civil monetary penalties (CMPs).

Here are five things healthcare organizations should know about healthcare exclusions:

The OIG Permits Early Reinstatement for Some Exclusions

The OIG created an early reinstatement process in the Final rule published on January 12, 2017. The rule explains the specific exclusions eligible for early reinstatement, but also clarifies when early reinstatement will not be an option. If an individual’s license revocation or suspension was for reasons related to patient abuse or neglect, the OIG will not consider an application for early reinstatement, according to the rule.

“The process is somewhat complicated and depends on individual circumstances,” Jeff Overley states in a Law360 article. “For example, someone might be eligible if they get a new license and can demonstrate that they’ve resolved the issues that led to license revocation.”

Healthcare Exclusions Can Be Imposed for Decades

While the length of healthcare exclusions can vary depending on individual circumstances, some exclusions can be imposed for decades. For example, take the case of unlicensed New Jersey dentist Roben Brookhim, who agreed to pay $1.1 million and accept a 50-year exclusion from participating in federal healthcare programs as part of a settlement to resolve his administrative liability for false claims to Medicaid, billing for services furnished by an excluded person, and owning and controlling a Medicaid-participating entity while he was excluded. “Fifty years is one of the longest exclusion periods ever imposed by our office,” Gregory E. Demske, Chief Counsel to the DHHS Inspector General, stated in a press release.

The OIG Publishes Special Advisory Bulletins on Exclusions

In order to help healthcare compliance officers understand healthcare exclusions better and to provide clarification and guidance, the OIG occasionally publishes Special Advisory Bulletins from time. In 1999, the OIG’s Special Advisory Bulletin clarified that reinstatement does not occur automatically at the end of a term of exclusion, but rather, an excluded party must apply for reinstatement. 2013’s Special Advisory Bulletin was significant because it established monthly exclusion screening as the best practice in the industry, in order to minimize the level of risk for a healthcare organization. Check out PreCheck’s recap of this advisory bulletin in this blog post.

The Critical Role of State Medicaid Exclusion Lists

The OIG’s List of Excluded Individuals and Entities (LEIE) is not the only exclusion list healthcare organizations should screen on a regularly basis. In 2015, the OIG published a report indicating 1 in 10 providers terminated in one state continue to treat Medicare patients in another state. This is significant because Section 6501 of the Patient Protection and Affordable Care Act (ACA) requires States to terminate providers who have been terminated under another State’s Medicaid program. Additionally, not all state exclusions make it to the OIG’s federal list of exclusions. Currently, there are 34 State Medicaid Exclusion Lists and they should be a part of every healthcare organization’s exclusion screening program.

Stay Ahead with the OIG’s Resources and Tools

The DHHS-OIG provides a variety of resources for healthcare organizations who want to learn more about exclusions. They have a section on their website dedicated to exclusions. As an example, their video below provides an overview of exclusions.


Keeping up with healthcare exclusions and conducting monthly screenings can be a daunting task, but there are many resources for healthcare organizations. If you need help optimizing your exclusion screening program, ask us how our SanctionCheck service can help.

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