Understanding OIG Exclusions, Medicaid Terminations, and SAM Debarments is essential for healthcare organizations when hiring skilled professionals to avoid Civil Monetary Penalties.
OIG Administrative Actions
Providers excluded by the OIG (Office of the Inspector General) or terminated by any State Medicaid Program Authority are prohibited from participating in Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP) federally funded healthcare programs.
Sanctions and Exclusions are administrative actions taken by the Office of the Inspector General (OIG) for conviction of criminal offenses or for other discretionary reasons.
A sanction results from an administrative hearing in which an individual or entity violates an administrative rule, a civil law, or a criminal offense and may entail various penalties.
Sanctions are enforced by the Office of the Inspector General (OIG) or a State Medicaid program authority.
A sanction from a healthcare disciplinary or licensing board can lead to significant consequences, the most severe of which is an exclusion.
An exclusion results from an extreme sanction issued by the Office of Inspector General (OIG). Exclusions are typically reserved for those who pose a high risk to patients or a program’s integrity.
The OIG penalizes providers by excluding them from participation in federal healthcare programs, including Medicare, Medicaid, CHIP, and TRICARE.
Additional actions against the excluded party may include license restrictions, revocation, suspension, or voluntary surrender of the license. These are also referred to as disciplinary actions against the license.
40% of excluded providers on the OIG’s List of Excluded Individuals and Entities (LEIE) have their licenses sanctioned or revoked.
Once an individual or entity is added to the LEIE, they are prohibited from participating in federal or State healthcare programs.
Additionally, an OIG exclusion can result in debarment from the General Services Administration (GSA) System for Award Management (SAM) and termination from State Medicaid programs.
Learn more about OIG Exclusions Authority.
Mandatory Exclusions
The OIG is required by law to exclude from participation in all federal healthcare 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 also has the discretion to exclude individuals and entities on several other 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.
CMS Administrative Actions
Providers whose billing privileges have been revoked by the Centers for Medicare & Medicaid Services (CMS) or any State Medicaid program authority are prohibited from participating in Medicare.
The Centers for Medicare & Medicaid Services (CMS) defines “termination” as the action taken by a State Medicaid Program Authority to revoke a provider or supplier’s billing privileges and terminate the provider’s participation in Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) program, “for cause.”
For the most part, an “exclusion” is a penalty imposed by the OIG for violation of federal law, whereas a “termination” is the loss of billing privileges imposed by the State.
Effectively, both result in the provider’s involuntary removal from the federal Medicare, Medicaid, and CHIP healthcare programs.
Termination “for cause” may include, but is not limited to, reasons based on fraud, integrity, or inadequate quality.
“For cause” does not include cases where a State terminates a Medicaid or CHIP provider due to inactivity and for failure to submit claims.
“For cause” also does not include voluntary action the provider takes to end their participation in the program, except where that “voluntary” action is taken to avoid sanction.
For example, suppose a provider submits a request to the State to “voluntarily” terminate its provider agreement to avoid sanctions for noncompliance. In that case, this does not qualify as a voluntary action.
CMS has the authority to “terminate” providers for various reasons:
Failure to provide ownership information and noncompliance with civil rights requirements.
Knowingly and willfully made, or caused to be made, any false statement or representation of a material fact for use in an application or request for payment under Medicare.
Submitted, or caused to be submitted, requests for Medicare payment of amounts that substantially exceed the costs it incurred in furnishing the services for which payment is requested.
Furnished services that the OIG has determined to be substantially more than the needs of individuals or of a quality that fails to meet professionally recognized standards of health care.
The provider or supplier is out of compliance with enrollment requirements (e.g., lacks a physical business address to render services) and hasn’t submitted a corrective action plan.
The provider or supplier lost their license.
The provider or supplier no longer meets CMS regulatory requirements for its specialty.
The provider or supplier lacks a valid Social Security number or employer identification number and an owner, partner, managing organization/employee, officer, director, medical director, and/or authorized official.
The provider or supplier is excluded from Medicare and other federal health programs or debarred from government contracts, which means the provider is barred from doing business with Medicare directly or indirectly (e.g., as a hospital employee).
Felonies will prompt the revocation of billing numbers and, thus, Medicare terminations.
These include felonies against people (e.g., murder, rape, assault), financial crimes (e.g., insurance fraud, embezzlement, extortion, tax evasion), felonies that put Medicare money or beneficiaries “at immediate risk,” and felonies that trigger mandatory exclusion.
The provider or supplier includes false or misleading information on Medicare enrollment forms, yet certifies it as accurate.
The provider or supplier neglects to provide complete and accurate information and supporting documentation within 30 days of CMS ordering the submission of an enrollment application and supporting documentation.
The physician, non-physician practitioner, physician organization, or non-physician organization fails to report changes in adverse actions and practice locations to CMS within 30 days.
SAM Administrative Actions
But why do I need to screen both OIG Exclusions and SAM Debarments for exclusion from Medicare, Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP) federal healthcare programs?
Both OIG Exclusions and SAM Debarments are required because they serve distinct, though overlapping, purposes in protecting federal funds and programs.
A suspension is a preliminary action taken by a Suspending and Debarring Official (SDO) to temporarily exclude a party from eligibility for new Federal Procurement and Non-procurement Awards.
Suspensions are applied pending completion of an investigation, audit, or review, or of a judicial or administrative proceeding that may ensue. If legal or debarment proceedings have begun, the suspension may continue until those proceedings conclude.
However, if legal or debarment proceedings have not started, a suspension may not exceed twelve (12) months.
The SDO may grant a one-time extension of the 12-month limit for six (6) months.
A debarment is the final action taken by the Suspending and Debarring Official (SDO) to exclude a party from eligibility for new Federal Procurement and Non-procurement Awards.
Debarment is a suspension for a fixed, specified period, generally not to exceed three years.
The SDO has discretion to reduce or extend that time as needed to protect the Government’s interests.
There are procurement and non-procurement regulations that form the suspension and debarment regulations framework.
Procurement regulations
48 CFR Subpart 9.4 – Federal Acquisition Regulation (FAR)
48 CFR Part 1409 – Department of Interior Acquisition Regulation
Non-procurement regulations
2 CFR Part 180 – Office of Management and Budget (OMB) Guidelines to Agencies on Government-wide Debarment and Suspension
2 CFR Part 1400 – Nonprocurement Debarment and Suspension
Search all Exclusions at Once
HealthProviders DB is an extensive database featuring over 9 million comprehensive Healthcare Provider Profiles, updated daily!
Exclusions are imported as they become available, keeping the Healthcare Provider Profiles up to date.
Learn more about who needs to be screened for exclusion from all federal healthcare programs.
Enter an NPI number, license number, or provider name in the search field below to search the Exclusions.
Exclusions that match by NPI number, or by full name and address, are “Exact” matches.
Alternatively, you can also search the Providers.
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Select a State to view the list of Exclusions by State.
Additionally, you can narrow the list by city, among other options, from the Filter Panel, which you can open by clicking the vertical ellipses ⋮ in the upper right corner of the app.
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