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), and all available State Exclusion lists, but what’s the difference, and why screen againgt all these lists?
Exclusion Screening Regulatory Requirements
Federal database checks — 42 CFR Part §455.436 regulations, all 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.
OIG Federally Funded Programs Exclusion Authority
The OIG is a federal agency with authority under Sections 1128 and 1156 of the Social Security Act (Act) to exclude individuals or entities from federally funded healthcare programs, including Medicaid, the Children’s Health Insurance Program (CHIP), and Medicare, and to seek Civil Monetary Penalties (CMPs) for various types of prohibited conduct.
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.
The Office of Inspector General (OIG) maintains the List of Excluded Individuals/Entities (LEIE) that is updated monthly.
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.
SAM Federal Contracts Procurement Repository
The General Services Administration (GSA) System for Award Management (SAM) lists individuals and entities suspended or 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.
Healthcare organizations should not hire individuals or entities on the SAM.gov list to avoid conducting business with a sanctioned, debarred, or excluded party.
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 lacks jurisdiction over such matters.
Who needs to be screened?
Healthcare organizations must screen new hires and regularly monitor current employees, as well as the individuals and entities with whom they do business, to avoid potential Civil Monetary Penalties.
This includes doctors, nurses, pharmacists, and other healthcare professionals interacting with patients and federal healthcare programs, such as Medicare or Medicaid.
Even if someone isn’t directly providing care, they might still be involved in billing, patient records, or managing payments from federal programs. These roles are critical, and OIG exclusion checks should apply here.
Think of anyone supplying medical equipment, pharmaceuticals, or services to a healthcare organization. Just because someone isn’t a full-time employee doesn’t mean they shouldn’t be checked. They must pass an OIG background check if they provide goods or services involving federal funds.
Volunteers can be involved in patient care or sensitive healthcare operations in specific settings. While not always required, screening volunteers can help ensure the organization maintains compliance with federal regulations.
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.