Q: Which exclusion list should I use to check employees and vendors, the OIG-LEIE or the GSA-SAM?
It is recommended that you check both the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) and the General Services Administration’s (GSA) System for Award Management (SAM) databases as well as all of the publicly available State Medicaid Exclusion Lists.
According to 42 CFR Part §455.436(b) — Federal database checks, State Medicaid agencies must:
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) (formally the Excluded Parties List System (EPLS)), and any such other databases as the Secretary may prescribe.
Q: How frequently should I check for exclusions and sanctions?
According to the OIG’s Special Advisory Bulletin issued in May 2013, healthcare organizations recommended that providers check their employees and contractors against the OIG-LEIE each month because the LEIE is updated monthly.
According to 42 CFR Part §455.436(c)(2) — Federal database checks, State Medicaid agencies must:
Check the LEIE and SAM (formerly the EPLS) no less frequently than monthly.
Furthermore, monthly screening is mandatory in at least fourteen states, while many others strongly suggest that providers screen employees and vendors against their state list and the LEIE monthly.
For example, Hawaii states on its Medicaid website that any provider who participates in the Medicaid program must search Hawaii’s excluded provider list monthly and the LEIE annually to determine whether an employee or contractor has been excluded from participating in the Medicaid program.
Kentucky mandates monthly screening against Kentucky’s state Medicaid list, the OIG-LEIE, and the GSA-SAM.
New Jersey made exclusion searches mandatory in 2010. New Jersey providers and HMOs are responsible for verifying all “current and prospective employees (regular or temporary), contractors or subcontractors who directly or indirectly will be furnishing, ordering, directing, managing or prescribing items or services in whole or in part are not excluded, unlicensed or uncertified by searching the following databases monthly: OIG-LEIE, NJ Treasurer’s Exclusions Database, NJ Division of Consumer Affairs licensure database, NJ Department of Health and Senior Services licensure database, Certified Nurse aide and personal care assistant registry, and National Provider Database (NPDB).
Providers are reminded that if you are a provider in North Carolina and one of your employees is on Hawaii’s excluded provider list, you have violated the exclusion provisions. Under ACA Section 6501, an individual or entity excluded from one state’s Medicaid program is excluded in all states. So, providers need to conduct monthly exclusion screening checks of the LEIE, GSA-SAM, and all state lists.
Healthcare organizations should check everything—the OIG LEIE, the GSA SAM, and the State Medicaid Exclusion Lists—every month to ensure they check every available source with the latest information.
Q: Are there regulatory requirements for healthcare organizations to check for exclusions or sanctions?
Per 42 CFR Part §455.436 — Federal database checks, State Medicaid agencies must do all of the following:
(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) (formally the Excluded Parties List System (EPLS)), 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 (formerly the EPLS) no less frequently than monthly.
If your organization fails to screen for excluded individuals and entities, you could be subject to Civil Monetary Penalties (CMP).
Q: Should an employee excluded from federal health programs in another state over 10 years ago be terminated?
Section 6501 of the Affordable Care Act (ACA) requires States to terminate the participation of any individual or entity if they are terminated under Medicare or any other Medicaid State Plan.
At first glance, termination seems reasonable in this situation. However, this only applies to terminations occurring on or after January 1, 2011, the effective date.
If this particular employee were excluded in 2004, for example, they would be excluded only in the state that excluded them. Thus, if the state that excluded them is not your state, the Affordable Care Act does not mandate that you terminate them.