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Lilly Hummel
(202) 898-2845
lhummel@ncal.org

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Exclusion Lists

 

The OIG (Office of Inspector General) maintains a list of individuals and entities (LEIE) that are excluded from participation in Medicare, Medicaid and other Federal health care programs. An individual or entity listed on the LEIE cannot be employed, in any capacity, by a health care provider that receives reimbursement from any Federal health care program. There are two types of exclusions — mandatory and permissive.


Mandatory exclusions require OIG to exclude individuals and entities convicted of criminal offenses such as Medicare or Medicaid fraud or patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription or dispensing of controlled substances.


Permissive exclusions give OIG discretion to exclude individuals and entities for various reasons including misdemeanor convictions related to health care fraud; fraud in a program (other than a health care 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 health care 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 health care program; engaging in unlawful kickback arrangements; defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer or management employee. Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP).


The General Service Administration’s (GSA) System for Award Management (SAM) contains additional information about individuals and entities that have been debarred or suspended from doing business with the federal government, and is not included in the OIG’s LEIE. Providers have an “affirmative duty” to check both the LEIE and the SAM to ensure that excluded individuals are not in their centers, otherwise they face significant fines. Some state also are now requiring providers to regularly check State exclusion lists.

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