What is an Exclusion and why do I need to search the OIG Exclusion List
The OIG Exclusion List:
With the passage of the Affordable Care Act on March 23rd, 2010, President Obama put into place a comprehensive health insurance reform that will change the way healthcare is delivered for the foreseeable future. As a part of these changes, The Office of the Inspector General (OIG) imposed and maintains a list of exclusions under the authority of sections 1128 and 1156 of the Social Security Act.
The List of Excluded Individuals/Entities (LEIE):
The OIG’s list of excluded individuals and entities exists to provide information regarding excluded providers to the health care industry and the general public. This list includes both individuals and entities currently excluded from participating in all Federal health care programs including Medicare and Medicaid. Any individual or entities that have resolved their exclusion and have been reinstated are removed from the LEIE.
Before excluding a provider, the OIG sends out a written Notice of Intent to Exclude, which includes the basis for the intended exclusion and an explanation of the potential effect of an exclusion. If the issue remains unresolved after 30 days, the OIG will send a final Notice of Exclusion. The exclusion becomes effective 20 days following this notice is mailed and becomes public information.
What is an Exclusion?
An exclusion often arises as a result of a sanction (disciplinary action) against a licensed health care provider. Providers can get excluded for committing certain felonies, misdemeanors, or even failing to pay their college loans, but more than 40% of the time excluded providers on the OIG LEIE get there because their license has been sanctioned or revoked.
Practically, an exclusion prohibits a provider from participating in Medicaid, Medicare, and other Federal health care programs. This means any health care provider that receives reimbursement from any Federal health care program cannot employ an excluded individual or entity. Not only will no payment be made by any Federal health care program for any items or services provided by an excluded individual or entity, but health care providers could potentially face fines among other penalties.
Why do I need to search to OIG Exclusion List?
By law it is a health care provider’s responsibility to self-disclose if you identify an excluded provider. To avoid the negative effects of employing an excluded individual or entity, health care providers should continually search the OIG exclusion list.
Not only should health care providers check for exclusions, but they should also be aware of any sanctioned individuals or entities employed. As 40% of all exclusions begin with a sanction, being aware of sanctions gives you the ability to make decisions before an exclusion is levied. It is also vital to be aware of the due process in states where sanctioned or excluded providers may have moved from in the past as Section 6501 of the Affordable Care Act dictates that if a provider is excluded in one state, they’re excluded in all states.
There are about 27 Exclusion lists you should be checking on a monthly basis as well as over 1,600 Sanction lists you should also check to get an early indicator of disciplinary actions against your providers.
What do I do if I find an excluded provide?
If you identify an excluded individual or entity from the OIG exclusion list, check the Special Advisory Bulletin of the Effect of an Exclusion for guidance. If you are currently employing or have employed the individual or entity while excluded, check the Self-Disclosure protocol.