The Office of Inspector General (“OIG”) has the authority to exclude individuals and entities from Federally funded health care programs pursuant to section 1128 of the Social Security Act (“Act”) (and from Medicare and State health care programs under section 1156 of the Act) and maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (“LEIE”). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (“CMP”).
Exclusions are imposed for numerous reasons:
Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses:
- Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs,
- 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: OIG has discretion to exclude individuals and entities based on various actions, including (but not limited to):
- Misdemeanor convictions related to health care fraud other than Medicare or a State health program,
- 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 loans or scholarship obligations, and
- Controlling a sanctioned entity as an owner, officer, or managing employee.
The effects of an exclusion are outlined in the Updated Special Advisory Bulletin on the Effect of Exclusion From Participation in Federal Health Programs, but the primary effect is that no payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This includes Medicare, Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).
The HHS OIG has updated the LEIE which lists of all currently excluded individuals and entities. Healthcare providers should ensure that at a minimum:
- All new hires are checked against the LEIE at the date of hire,
- All employees are checked against the LEIE annually,
- All vendors are checked against the LEIE at the time of initially purchasing supplies or services, and
- All vendors are checked against the LEIE annually.
The updated LEIE database is available here. The list can be downloaded and sorted in any manner making your review easier.