When it comes to protecting patients and preventing fraudulent, wasteful, and abusive practices in healthcare, there’s perhaps no better resource than the Office of Inspector General Exclusion List.
This database is a crucial resource for healthcare organizations throughout the United States — but, in order to properly monitor it and identify potential bad actors, it’s important that you fully understand what it is, how it works, and what purpose it serves for providers and facilities.
In this installment of our ongoing OIG compliance series, learn all of this and more, including how Vālenz Health® can help improve your exclusion list monitoring process.
What is the OIG Exclusion List?
The Office of Inspector General Exclusion List (also known as the OIG’s List of Excluded Individuals and Entities [LEIE]) is 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.
This list exists to help healthcare organizations prevent the criminal and civil penalties that come from working with providers linked to dishonest practices like fraud, abuse, waste, or neglect.
In addition to the federal OIG Exclusion List, every U.S. state and territory has its own Office of Inspector General (or equivalent), its own laws and regulations, and, in most cases, its own databases. While federal-level exclusions will typically trigger an automated state-level exclusion, the reverse is not necessarily true.
It’s recommended that healthcare organizations continuously monitor the OIG Exclusion List (and other relevant exclusion lists) to identify and avoid hiring bad actors.
Types of OIG Exclusions
There are two types of OIG exclusions: mandatory and permissive exclusions.
While both exclusions carry the same weight (both categories prevent participation in federal healthcare programs), the classification stems from the severity of offenses committed to appear on the OIG Exclusions List.
Mandatory Exclusions
The OIG is required by law to manually exclude individuals and entities convicted of certain types of criminal offenses, including:
- Offenses related to the delivery of an item or service under Medicare or a state healthcare program
- Patient abuse or neglect
- Felony convictions for other healthcare-related fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct
- Felony convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance
Permissive Exclusions
The OIG also has the discretion to exclude individuals and entities on a number of other grounds, including (but not limited to):
- Misdemeanor convictions related to healthcare fraud not involving Medicare or a state health program
- Fraud in a program (other than a healthcare program) funded by any federal, state, or local government agency
- Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
- Suspension, revocation, or surrender of a license to provide healthcare for reasons bearing on professional competence, professional performance, or financial integrity
- Provision of unnecessary or substandard services
- Submission of false or fraudulent claims to a federal healthcare program
- Engaging in arrangements that violate the federal Anti-Kickback Statute
- Defaulting on health education loan or scholarship obligations
- Controlling a sanctioned entity as an owner, officer, or managing employee
Despite its name, a permissive exclusion is no less serious than a mandatory exclusion in terms of consequences. Just because an individual or an entity has not been part of any activity that would require the OIG to hand out a mandatory exclusion does not mean that they haven’t been given a permissive exclusion for something else entirely.
Both exclusions mean the same thing: that a provider or entity is barred from participating in federal healthcare programs due to improper activities or behavior.
SAM Exclusion Matches
We can’t talk about OIG Exclusion Lists without mentioning other relevant sanction and exclusion lists that fall outside the healthcare field but are no less important when it comes to OIG exclusion monitoring.
Specifically, organizations should consider the System for Awards Management (SAM) program, which houses sanction and exclusion lists for many federal agencies, including the Department of Justice, the Environmental Protection Agency, and many more.
At first glance, it may be hard to understand why the OIG recommends monitoring SAM when many of these federal agencies aren’t tied directly to the healthcare field. However, OIG exclusion monitoring recommendations seek to add protection to everyday citizens on multiple levels, one of those being to prevent known bad actors in other fields and industries from entering the healthcare system.
Here’s an example:
In March 2024, the Department of Defense filed a complaint against six health plans participating in the Uniformed Services Family Health Plan (USFHP) program. Through the USFHP program, the DOD pays plans capitated rates to provide healthcare services to their enrollees.
The complaint alleged that defendants violated the False Claims Act by knowingly retaining erroneously inflated payments for healthcare services that the health plans had been contracted to provide to retired military members and their families. According to the complaint, in June 2012, the plans learned of calculation errors that had inflated the rates they had been paid in prior years; nevertheless, the plans took steps to conceal the overpayments from the government and continued submitting invoices at the inflated payment rates — indicating an ongoing issue of fraud.
Because the DOD budget is derived from the taxes of United States citizens, by knowingly defrauding the DOD, USFHP has essentially defrauded the American public. While this may seem pedantic at a certain level, it serves as a good illustration of how the OIG exclusion recommendations seek to protect the public by handing down exclusions to bad actors throughout the field of healthcare, not just doctors and hospitals.
Bottom line: If healthcare organizations were to only check the OIG-specific exclusion list, these bad actors could have the chance to slip into the healthcare industry undetected, prey on everyday citizens, and ultimately waste taxpayer dollars on their own designs.
The Challenges of Monitoring SAM Exclusion Lists
Despite the best efforts by OIG and related federal programs, federal and state databases may not always have detailed information on potential exclusion matches — making it difficult for healthcare organizations to compare their provider list against those on the exclusion lists.
The SAM database consolidates all the separate government agencies’ (such as the EPA, DOJ, and OPM) sanction lists into one. These agencies generally have the date of birth or partial social security number on file; however, SAM does not include this information within its sanction data, often listing only an individual’s first/last name and location. For this reason, the actual sanctioning agency must be contacted via phone or email to verify any additional information against your search data.
Fortunately, the Office of Inspector General Exclusion List contains many more data points to help verify any potential sanctioned providers and entities.
The Importance of OIG Exclusion List Monitoring
We’ve previously discussed the importance of OIG compliance monitoring at length, but it’s worth repeating here: By ensuring that the individuals and entities your organization employs and interacts with are not on any exclusion lists, you avoid bringing costly lawsuits and civil monetary penalties from the OIG to your doorstep.
If you do discover that your organization has employed an individual or has contracted with an entity on the OIG Exclusion List, it’s best to speak to your legal counsel and explore the OIG’s self-disclosure process.
More information on that process can be found on the OIG website.
Improve Your OIG Compliance Monitoring with Vālenz Health®
Successfully monitoring the OIG Exclusion List, state exclusions lists, SAM EPLS, and the myriad of other sanction/exclusion lists available is a time-consuming task, even for highly trained, multi-person compliance teams.
Valenz Provider Staff Sanction Monitoring solves for those challenges with an all-in-one software/support solution that does the monitoring for you, allowing you to quickly identify and respond to potential risks.
By customizing our solution to your unique organization needs, we save you valuable time, money, and stress caused by ongoing exclusion list monitoring — giving your team one less thing to worry about each month.
Learn more about Provider Staff Sanction Monitoring and how it can enhance your OIG exclusion screening by contacting a Valenz team member today.
