Individuals who engage in fraud or abuse in the healthcare industry can put patients and taxpayers at risk of physical or financial harm. For this reason, the U.S. Office of the Inspector General (OIG) can exclude certain people or organizations from providing services under federally funded healthcare programs. 

Healthcare providers that arrange or contract with excluded individuals can be subject to civil monetary penalties. To reduce risk to their organization and their patients, all healthcare providers should include OIG exclusions in their pre-employment and continuous screening program.

What is an OIG Exclusion?

The U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG) was established to protect HHS programs and their recipients. HHS-OIG operates throughout the United States to find and prevent fraud and abuse in HHS programs, and has the authority to exclude people or entities from federally funded healthcare programs. 

This exclusion can happen for a variety of reasons, including: 

• Conviction for Medicare or Medicaid fraud
• Conviction for other fraud offenses that involve federal or state healthcare programs
• Patient abuse or neglect
• Felony convictions for other types of healthcare fraud, theft, or other financial misconduct
• Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances
• Engaging in unlawful kickbacks
• Provision of unnecessary or substandard services
• Defaulting on health education loan or scholarship obligations
• Felony conviction for sexual assault
• License revocation for any of the above actions

Some of these reasons lead to mandatory exclusions, where the OIG is required by law to exclude the individual or entity from federal healthcare participation. Others, known as permissive exclusions, can be made at the discretion of OIG.

Once excluded, an individual or entity can receive no payment for services under any federal healthcare programs. However, an exclusion does not affect the ability to receive benefits under federal programs.

Healthcare HR departments should make HHS-OIG exclusions part of their screening of all candidates, new hires, and current employees. Here are some of the best practices for conducting OIG exclusion screening.

1. Refer to the List of Excluded Individuals/Entities (LEIE).

OIG maintains an LEIE that provides information to the healthcare industry, its patients, and the public. An individual or entity may be reinstated and removed from the LEIE.

The LEIE is available either as an Online Searchable Database, which allows users to search for an individual or entity’s name. If there is a match, the database can verify with an individual's Social Security Number or Employer Identification Number. An alternative is the Downloadable Database, which users can download to a personal computer. This database can be merged with monthly updates to maintain accurate information about exclusions and reinstatements.

2. Conduct Monthly Exclusion Screening.

A 2013 advisory bulletin by OIG made monthly exclusion screening a healthcare industry standard. Because a one-time, pre-employment exclusion screening may not be sufficient, healthcare organizations should conduct recurring exclusion checks after an employee has been hired. Since the LEIE is updated monthly, exclusion screening should be conducted with the same frequency to minimize risk.

3. Stay Up-to-Date on State Medicaid Exclusion Lists.

Healthcare HR departments and compliance officers should be proactive when it comes to awareness of state Medicaid exclusion lists. Many states have their own exclusion list which is separate from the OIG LEIE. If your organization is not screening against the state lists, your exclusion screening program may not be thorough enough.

4. Establish Collaboration Between Departments.

Because exclusion screening can affect the entire healthcare organization, it is important for different teams to work together to screen for OIG exclusion. Healthcare compliance officers should work with the healthcare organization’s HR team to ensure employees are monitored for exclusions monthly.

5. Use a Comprehensive Exclusion Screening Solution to Drive Efficiency.

A comprehensive exclusion screening solution can streamline this process for your organization by identify individuals who have been excluded, terminated, sanctioned, or debarred from the various federal and state programs. For example, individuals or entities who are on the OIG LEIE may also be debarred or sanctioned under the General Services Administration (GSA) Excluded Parties List System, which excludes individuals or entities from receiving federal contracts. Using a full service exclusion solution such as PreCheck’s SanctionCheck® can help your organization ensure thorough, accurate screening and reporting results.

Thorough, regular exclusion screening monitoring can help protect your healthcare organization’s reputation, preserve patient safety, and ensure compliance with federal guidelines. Following these best practices for OIG exclusion screening monitoring can help your healthcare organization avoid penalties and streamline compliance.