With associated financial penalties tallying in the billions per year, non-compliance with the Office of Inspector General standards is simply not an option for healthcare organizations.
Unfortunately, the work required to stay compliant — consistently monitoring exclusion lists, identifying bad actors, and staying audit-ready — is often easier said than done.
In this installment of our series on OIG compliance, we dive into the strategies and processes required for comprehensive OIG compliance monitoring. Learn what’s involved, why it’s so important, and how a partner like Vālenz Health® can help you successfully maintain compliance and deliver smarter, better, faster healthcare for all.
What is OIG Compliance Monitoring, and Why is It Important?
As part of the Department of Health and Human Services, the Office of Inspector General (OIG) is a federal agency dedicated to combatting fraud, waste, and abuse through government oversight.
The OIG maintains a list of recommended compliance strategies and resources for any healthcare organizations that work with the federal government. This includes the OIG List of Excluded Individuals and Entities (LEIE), a list of providers and organizations that are prohibited from participating in federal health care programs, including Medicare, state healthcare programs, Veterans Affairs, and more.
OIG compliance monitoring is an ongoing strategy to comply with those set standards by continuously reviewing sanction and exclusion lists, maintaining proper documentation for future audits, and much more. This monitoring process can be as in-depth or simple as an organization deems necessary for its needs, and it can be aided by external programs and solutions, such as Valenz Provider Staff Sanction Monitoring.
By meeting OIG compliance standards, organizations not only prevent occurrences of fraud, waste, and abuse within their processes. They also avoid costly lawsuits and fines associated with non-compliance.
In 2024 alone, the OIG reported 1,548 criminal and civil enforcement actions, totaling more than $7.13 billion in expected recoveries and receivables. Several of these cases were worth millions in and of themselves; one enforcement action resulted in jail terms and an order to pay more than $424 million in restitution for fraudulent medical equipment sales.
It’s worth noting that settlements paid to the OIG do not take into account whether those individuals were excluded by other federal or state agencies, which carry their own separate penalties.
Monitoring Exclusion Lists
For healthcare organizations, perhaps the most important aspect of OIG compliance monitoring is ongoing review of sanction and exclusion lists. While it’s a time-consuming process, monitoring these lists is the most effective way to identify potential bad actors from being hired and/or working for your healthcare organization.
It’s recommended that organizations consistently monitor all of the following:
- OIG Exclusion List
- State- and territory-specific exclusion lists
- System for Awards Management (SAM) lists
While there is often some overlap between these lists, state-level exclusions will not always be included on federal lists — which is why detailed, ongoing monitoring of these lists is so crucial to catching bad actors before they can do damage at your organization.
Your team can avoid wasting valuable time and energy combing through these lists by partnering with a service like Valenz Provider Staff Sanction Monitoring. Our comprehensive software does the monitoring for you across multiple sources to alert of any potential risks.
Learn more about this solution (and how we can customize it to your unique organizational needs) by contacting a Valenz team member today.
Verifying Possible Exclusion Matches
As you conduct your OIG compliance monitoring, you’re likely to find potential matches at one point or another — but a match based on name alone is not enough evidence to go on.
To determine whether the person you are searching for and a listing in the sanction/exclusion lists are the same individual, you’ll need to do some additional verification. Otherwise, you expose your organization to Fair Credit Reporting Act (FCRA) claims and further legal issues.
How to Verify a Possible Match
When a possible match appears during your OIG compliance monitoring, you may be able to verify it with information you already have or can easily retrieve, such as a date of birth or Social Security number.
If you are presented with a possible match, follow these verification steps:
- Step 1: Check for verifiable information in the record details: Does the possible result give a date of birth for the sanctioned/exclude individual? If not, does it give a middle name? If that data is available but does not match that of the searched party, it’s unlikely that you have a positive match.
- Step 2: Look for additional information from the agency: Once you determine the original sanctioning/excluding agency for the match, try to locate the possible result within the original source to see if more information could allow you to verify the match.
If no additional information is available after reviewing the possible result on the original source, then you’ll need to determine which method of further verification is required for the specific agency the result is coming from.
Verifying a Possible Match with Limited Information
How you go about verifying a possible match with limited information will often depend on where the sanction/exclusion is coming from, as certain sanction/exclusion agencies provide different methods of verification.
Usually, the verification processes fall into the following categories:
- Agencies like the OIG, New York OMIG, Texas OIG, Maine HHS, and Louisiana Medicaid have online verification tools you can use to verify a possible match within seconds, if you have your searched party’s SSN.
- Most agencies will have an email contact and/or a hotline where you can inquire about a possible match on their sanction/exclusion list. This contact information can usually be found on the same webpage that houses their sanction/exclusion list, though it can sometimes be found on the list itself.
If you need help verifying possible matches, consider partnering with an OIG compliance monitoring solution like Valenz Provider Staff Sanction Monitoring, which can offer expert support to identify and verify noncompliance risks on your behalf.
OIG Compliance Monitoring with Vālenz Health®
At Valenz, we’re committed to a strong, vigorous, and healthy vision of healthcare, and OIG compliance monitoring is an important part of that vision.
Our OIG compliance monitoring solutions ensure the highest level of compliance, allowing your organization to monitor sanction and exclusion lists like the OIG Exclusion List, SAM, and all available Medicaid databases in one system at the same time. We help you catch possible compliance issues in real time to protect your organization from legal and financial risks associated with federal lawsuits, penalties, and more.
Learn more about our OIG monitoring solution and how we can customize it for your organization by contacting a Valenz team member below.
