OIG Exclusions: A Beginner’s Guide

Posted by EverCheck on July 27, 2016


OIG Logo

If you're getting started in a healthcare compliance career, you're not alone. The U.S. Bureau of Labor Statistics estimates that the field will grow by 7% through 2024. With so many healthcare compliance requirements, it can sometimes feel like you're drinking water from a fire hose. In this article, we take OIG exclusions back to basics to help you understand what staying compliant entails. You can find other great resources directly from the OIG website, as well.


Who or what exactly is the OIG?

In healthcare, when someone refers to OIG they’re likely referring to the Office of the Inspector General for the Department of Health and Human Services. There are other Inspector General offices (for instance, the General Services Administration’s OIG), but the HHS OIG is the largest inspector general’s office within the entire US Federal system.


So they’re an office of a Federal agency. What do they do?

Consider the OIG, in part, the watchdogs for Health & Human Services programs - programs like Medicare and Medicaid and 100+ other HHS Federal programs. They’re looking out for things like fraud, waste, and abuse. This is a big deal since around 25% ($938B in 2015) of the total Federal budget goes to Medicare, Medicaid, CHIP, and ACA marketplace subsidies.


What’s their strategy?

OIG conducts audits, investigations, and evaluations across the US. These efforts result in OIG-developed and distributed resources that help those in the healthcare industry comply with waste and fraud abuse laws. They can also result in the criminal, civil, and administrative enforcement against individuals and entities directly associated with fraud or waste. In 2015 alone, the Federal Government won or negotiated more than $1.9B in health care fraud judgments and settlements.


I’ve heard of OIG Exclusions. What are they?

The OIG sometimes gives individuals or entities the red light from participating in and receiving payment from their programs like Medicare and Medicaid. Essentially this means that these programs aren’t going to cover the bill for any services, orders, or prescriptions an excluded provider furnishes. This includes administrative and management services, as well.

OIG Exclusions, Medicare Fraud


What is considered grounds for exclusion?

Individuals or entities can be excluded for a number of reasons, but OIG breaks exclusions down into two categories: mandatory and permissive.

Mandatory exclusions require the OIG, by law, to exclude from participation in all Federal health care programs. Examples of infractions considered for mandatory exclusion: Medicare or Medicaid fraud, patient abuse or neglect, felony convictions for other health care related fraud, theft, or other financial misconduct.

Permissive exclusions are discretionary. Although not required by law, OIG may exclude individuals and entities for reasons such as misdemeanor convictions related to health care fraud, unlawful manufacture, distribution, prescription, or dispensing of controlled substances, and more.

For a full list of exclusions reasons, see the OIG’s background information page.


How do I know who is excluded from participation in HHS programs?

OIG maintains a list of individuals and entities who are excluded from participation. This list, known as the List of Excluded Individuals/Entities or LEIE for short, is updated monthly. You can access the downloadable list here, or you can search for an excluded party by name here.


How often should healthcare organizations check the LEIE to make sure their providers, employees, and vendors aren’t on the lists?

The OIG recommends checking the list regularly to be sure that no prospective employees or current employees are excluded from participation in HHS programs. The OIG updates their list monthly, so checking each new list is imperative. The most recent LEIE, as of the date this article was published, contains more than 65,000 entries.


That’s a lot of entries. Is there an efficient way to cross-reference an employee roster with the LEIE?

If you’re searching for quite a few individuals or entities, it’s best to download the entire LEIE file and use the CSV file or a database program to perform the searches. There are also automated OIG exclusions monitoring services that will cross-reference your employee roster with the LEIE every month, automatically. These services will then alert administrators if there’s a match so they can investigate further.

Automated OIG exclusions monitoring

So there you have it, a quick-reference guide to OIG exclusions.

If you're interested in learning more about automated exclusions monitoring, visit https://evercheck.com/solutions/hr/exclusions-monitoring

Posted in: Exclusions Monitoring

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