Exclusions, Sanctions, and Terminations – What’s the Difference

The differences between Exclusions, Sanctions, and Termination are crucial for healthcare organizations to understand when hiring and retaining skilled professionals.

Sanctions

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 lead to 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.

Exclusions

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.

Reasons for Exclusions

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 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

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 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 loan or scholarship obligations.
• Controlling a sanctioned entity as an owner, officer, or managing employee.

Terminations

The Centers for Medicare & Medicaid Services (CMS) bulletin defines “termination” as when a State terminates a Medicaid or Children’s Health Insurance Program (CHIP) provider’s participation in the program, or when the Medicare program revokes a Medicare provider or supplier’s billing privileges.

An exclusion is a penalty imposed by the Office of Inspector General (OIG) on providers and suppliers who participate in federal healthcare programs, including Medicaid, CHIP, and Medicare, and who violate federal law.

Individuals and entities may be excluded from participating in federal healthcare programs for misconduct ranging from fraud convictions to patient abuse to defaulting on health education loans.

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 Medicaid, CHIP, or Medicare.

Should a provider be terminated if on an Exclusion List in another State?

Section 6501 of the Affordable Care Act, Termination of Provider Participation Under Medicaid if Terminated Under Medicare or Other State Plan, amends section 1902(a)(39) of the Social Security Act (Act) and requires State Medicaid agencies to terminate the participation of any individual or entity if such individual or entity is terminated under Medicare or any other State Medicaid plan.

However, a terminated provider could still work at healthcare organizations if they don’t provide services that are billable to Medicare. If they don’t bill Medicare directly for their services, they can still work in administrative roles at healthcare organizations.

For instance, a nurse practitioner who has been terminated (but not excluded) from Medicare could take on a different position at a hospital, as long as the services provided are not directly billable to Medicare.

Reasons for Termination

CMS has the authority to “terminate” providers for various reasons, including failure to provide ownership information and noncompliance with civil rights requirements.

Among the reasons for termination are:

1. “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.”
2. “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.”
3. “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.”
4. 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.
5. The provider or supplier lost its license.
6. The provider or supplier no longer meets CMS regulatory requirements for its specialty.
7. 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.
8. 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).
9. 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.
10. The provider or supplier includes false or misleading information on Medicare enrollment forms, yet certifies it as accurate.
11. 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.
12. 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.

Search HealthProviders DB

HealthProviders DB profiles include all Federal & State Exclusions, Terminations, Suspensions, Sanctions, and Debarments Lists, mapped as Exact or Possible matches, greatly simplifying your exclusion screening.

Exclusions that match by NPI number, or by full name and address, are Exact matches.

Exclusions are imported monthly as they become available, keeping the database up to date.

An individual or organization whose billing privileges have been revoked by the OIG or any State cannot participate in Medicaid, Medicare, or the Children’s Health Insurance Program (CHIP).

Enter an NPI number, license number, or provider name in the search field below to search the Exclusions.

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.

Use HealthProviders DB Batch Exclusion Screening and Exclusion-monitoring Solutions to avoid potential Civil Monetary Penalties.