You know it’s essential to screen new hires, current employees, and vendors against the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE), the General Services Administration (GSA) System for Award Management (SAM), plus all available State Exclusion lists, but what’s the difference, and why screen all these lists?
Federally Funded Healthcare Programs
The LEIE is the list of individuals or entities that the Office of Inspector General (OIG) has excluded from federally funded healthcare programs, including Medicaid, Children’s Health Insurance Program (CHIP), and Medicare programs.
The OIG is a federal agency with the authority under Sections 1128 and 1156 of the Social Security Act (Act) to exclude individuals or entities from federally funded healthcare programs and seek Civil Monetary Penalties (CMP) for various types of prohibited conduct.
Federal Contracts and other benefits
The General Services Administration (GSA) System for Award Management (SAM) is a list of individuals and entities suspended and debarred from obtaining new federal contracts, certain subcontracts (procurement), discretionary assistance, certain funded lower-tiered transactions, leases, loans, loan guarantees, and other benefits (non-procurement).
The GSA serves as a procurement repository and lacks the authority to impose financial penalties.
State Medicaid Programs
State Termination lists include individuals and entities that have had their Medicare provider or supplier’s billing privileges revoked and are terminated from participating in Medicaid, CHIP, and Medicare programs, for violating State laws.
Why screen both the LEIE and SAM?
The Federal Database Checks regulations — 42 CFR Part §455.436 mandate that State Medicaid Agencies must:
(a) Confirm the identity and determine the exclusion status of providers and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of Federal databases.
(b) Check the Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and any such other databases as the Secretary may prescribe.
(c)(1) Consult appropriate databases to confirm identity upon enrollment and re-enrollment; and
(c)(2) Check the LEIE and SAM no less frequently than monthly.
Why screen all State exclusion lists?
Section 6501 of the Affordable Care Act (ACA), “Termination of Provider Participation Under Medicaid if Terminated Under Medicare or Other State Plan”, requires State Medicaid programs and the Children’s Health Insurance Program (CHIP) to terminate the participation of any individual or entity that has been terminated from Medicare or any other State’s Medicaid program for cause.
This provision is intended to improve program integrity by ensuring that federal funds do not reach providers excluded for serious offenses such as fraud or abuse, regardless of the originating State’s termination.
There is no national list of State Medicaid program terminations. Although you may find some State Terminations in other State lists, it is not common.
There is no standardization; each state publishes its list in different formats and with varying levels of detail. Some states provide only the name of the excluded individual or entity, along with a possible address or, in some cases, just the city. To make matters worse, not all states offer a list of terminations.
The OIG List of Excluded Individuals and Entities (LEIE)
The Office of Inspector General (OIG) maintains the List of Excluded Individuals/Entities (LEIE) that is updated monthly.
HealthProviders DB imports the LEIE each month, so the database is always up to date. The LEIE data is normalized, aggregated, and matched with the Healthcare Providers’ Profile as Exact or Possible matches, greatly simplifying your research.
OIG Authority
The OIG has the authority under Sections 1128 and 1156 of the Social Security Act (Act) to exclude individuals and entities from federally funded healthcare programs for various reasons, including, but not limited to, convictions for Medicare or Medicaid fraud.
Section 1128 of the Act covers Medicare, Medicaid, and all other federal healthcare programs that provide benefits funded directly or indirectly by the United States.
Section 1156 extends this scope to include the state-level counterparts of Medicare and the health programs under Section 1128.
Mandatory Exclusions
The 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 and other crimes 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 healthcare-related fraud, theft, or financial misconduct.
- Felony convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
Permissive Exclusions
The OIG has the discretion to exclude individuals and entities on several grounds, including (but not limited to):
- Misdemeanor convictions related to health care fraud other than Medicare or a State Health Care 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 healthcare for reasons related to 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.
- Controlling a sanctioned entity as an owner, officer, or managing employee.
The System for Award Management (SAM)
The General Services Administration (GSA) maintains the System for Award Management (SAM), which lists individuals and entities that are suspended and debarred from participating in federal contracts, grants, loans, subcontracts, and other assistance programs.
Healthcare organizations should not hire individuals or entities on the SAM.gov list to avoid conducting business with a sanctioned, debarred, or excluded party.
HealthProviders DB imports the HHS and OIG Suspensions and Debarments daily, so the database is always up to date. The SAM Suspensions and Debarments are normalized, aggregated, and matched with the Healthcare Providers’ Profile as Exact or Possible matches, greatly simplifying your research.
Differences between OIG-LEIE and GSA-SAM
The two lists do often overlap regarding excluded healthcare providers. It is entirely possible to find the provider on both lists.
The Office of Inspector General has the authority to exclude individuals or entities from federally funded healthcare programs and to seek Civil Monetary Penalties (CMP) for various types of prohibited conduct. In contrast, the General Services Administration lacks the authority to impose financial penalties, as it serves as a procurement repository and does not have jurisdiction over such matters.
State Medicaid Exclusion Lists
Every state has a department or agency responsible for maintaining the integrity of its Medicaid programs and public health initiatives. While the names of these enforcement authorities may differ—such as the Department of Medicaid or the Department of Health Care Services—they all establish rules regarding the ineligibility of providers who have been disciplined or have lost specific licensing privileges.
Only forty-three states currently publish an exclusion list. New Mexico, Oklahoma, Rhode Island, South Dakota, Utah, Virginia, and Wisconsin do not keep a state exclusion list. Instead, you are referred to the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE).
Unfortunately, each state publishes its Medicaid exclusion lists in different formats and with varying levels of detail. Some states provide only the name of the excluded individual or entity, along with a possible address and, in some cases, just the city.
HealthProviders DB imports all state exclusion lists as they become available each month, ensuring the database is always up to date. State exclusion lists are normalized and matched with the Healthcare Providers’ Profile as Exact or Possible matches, greatly simplifying your research.
HealthProviders DB is an unparalleled solution to effortlessly and simultaneously search OIG Exclusions, SAM Exclusions, State Exclusion Lists, FDA Debarment, and Clinical Investigators—Disqualification Proceedings—all in one powerful platform!