Many people have never heard of this list, and what’s worse is that some people don’t even realize they are on it. How do people end up on the Medicaid Exclusion List, what are the consequences of being on the list, and can you ever get off the list?
How the OIG Exclusion Database Came to Be
HHS oversees the CMS (Center for Medicare Services), which administers the Medicare program. The Medicare Exclusion Database can trace its roots to 1996, when HIPAA (Health Insurance Portability and Accountability Act) was signed into law.
HIPAA authorized the OIG to provide guidance to the healthcare industry, to prevent fraud and abuse, and to promote high levels of ethical and lawful conduct. HIPAA’s mandate fit perfectly with OIG’s mission to identify and eliminate fraud, waste, and abuse in HHS programs and to promote efficiency and economy in Departmental operations.
How To Get on the Medicare Exclusion List
To meet these responsibilities, OIG audits, inspects, and investigates businesses and individuals nationwide to determine if they are meeting the legal and ethical standards of the Medicare program. Those who violate these standards are placed on the Office of Inspector General’s List of Excluded Individuals/Entities (LEIE), also known as the Medicare Exclusion List or the OIG Exclusion Database.
There are two types of exclusions issued by the OIG – Mandatory and Permissible.
Mandatory Exclusions result from criminal activities directly related to the federal Medicare or Medicaid program, or related state programs, including:
- Patient abuse or neglect.
- A felony conviction related to healthcare fraud, including theft, embezzlement, or bribery.
- A felony conviction related to controlled substances, including manufacture, distribution, prescription, dispensing, or theft.
Any of these activities result in an individual or business automatically being listed on the LEIE for five years. A second Mandatory Exclusion earns 10 years on the list, and a third offense results in Permanent Exclusion.
Unlike Mandatory Exclusions, the OIG has discretion regarding Permissible Exclusions.
Permissible exclusions can be issued for the following reasons:
- Misdemeanor conviction related to healthcare fraud. Baseline Period: three years
- Conviction related to fraud in non-healthcare programs. Baseline Period: three years
- Conviction related to obstruction of an investigation or audit. Baseline Period: three years
- Misdemeanor conviction related to controlled substance. Baseline Period: three years
- License revocation, suspension, or surrender. Minimum Period: period imposed by the state licensing authority
- Exclusion or suspension under federal or state healthcare program. Minimum Period: no less than the period imposed by federal or state healthcare program
- Claims for excessive charges, unnecessary services or services which fail to meet professionally recognized standards of healthcare, or failure of an HMO (Health Maintenance Organization) to furnish medically necessary services. Minimum Period: one year
- Fraud, kickbacks, and other prohibited activities. Minimum Period: none
- Entities controlled by a sanctioned individual. Minimum Period: same as length of individual’s exclusion
- Entities controlled by a family or household member of an excluded individual and where there has been a transfer of ownership/control. Minimum Period: same as length of individual’s exclusion
- Failure to disclose required information; supply requested information on subcontractors and suppliers; or supply payment information. Minimum Period: none
- Failure to grant immediate access. Minimum Period: none
- Failure to take corrective action. Minimum Period: none
- Default on health education loan or scholarship obligations. Minimum Period: until resolution of default or obligation
- Individuals controlling a sanctioned entity. Minimum Period: same as length of entity’s exclusion
- Making false statements or misrepresentations of material fact. Minimum period: none
- Failure to meet statutory obligations of practitioners and providers to provide medically necessary services meeting professionally recognized standards of healthcare (Quality Improvement Organization (QIO) findings). Minimum Period: one year
The OIG looks at a wide variety of factors in determining both the terms of permissible exclusions and whether to impose them.
As of January 2023, there were 3,244 businesses and nearly 74,000 individuals on OIG’s naughty list.
Consequences of Being on the OIG Exclusion Database
The law prohibits ANY payment for federal healthcare programs, items, or services furnished by an excluded individual, entity, or directed by an excluded physician, including administrative as well as clinical services.
Furthermore, the prohibition of payment remains in effect if the excluded individual has changed roles. The law expressly forbids any payments made to cover an excluded individual’s salary, expenses, or fringe benefits, regardless of whether they provide direct patient care. This includes any payments made to contractors, suppliers, or other third parties.
If a person does not disclose their status on the Medicare Exclusion List or if they are unaware that they are on the list, they are subject to a $10,000 fine for each service performed that results in payment for federal healthcare programs or services.
A business that employs or contracts with excluded individuals is subject to a $10,000 fine for each service performed by the excluded individual, and can also receive an additional assessment of up to three times the amount claimed for payment.
Believe it or not, there are those who don’t know they are on the Medicare Exclusion List. One reason is that excluded individuals or businesses must request removal from the list, even after their exclusion period has expired.
If you are concerned that you or someone you work with might be on the OIG exclusion list, or if you need further clarification on any matter related to the exclusion list, check the OIG Exclusion Website.
Read more about medicare compliance.