Exclusion Screening

What is exclusion screening?

Exclusion screening is the process of verifying that current or potential employee/contractor are not classified as an excluded individual who is prohibited from participation in any Federal health care program.

How is the OIG involved?

The Office of Inspector General (OIG) is authorized to exclude individuals and entities from federally funded healthcare programs under sections 1128 and 1156 of the Social Security Act.

OIG requires employers to conduct screenings for all new employees before extending offers of employment. Additionally, monthly screenings must be completed to align with OIG’s monthly release of newly excluded individuals or entities.

What does this mean for my practice?

Anyone who hires an excluded individual or works with an excluded entity may be subject to civil monetary penalties, as such Total Medical Compliance’s solution will allow you to screen all new employees before an offer of employment is made, as well as automate monthly screenings per the OIG’s monthly release of newly excluded individuals or entities.

Non-compliance with these requirements could result in financial penalties and jeopardize participation in Federal healthcare programs. Furthermore, per the OIG, no payments will be made for any items or services furnished by excluded parties, which includes Medicare/Medicaid and all other Federal health benefit programs.

What databases does TMC screen?

TMC’s service checks all databases.

LEIE – List of Excluded Individuals and Entities
SAM – System for Award Management
44 State Databases

Any individual or entity found on the exclusion’s list employed by a practice or entity that accepts government/state funded healthcare must check the database or be subject to civil monetary penalties. And will have to return any payments made in which the excluded individual was a part of the care.

These penalties range between $10,000 and $50,000 per violation.

What’s the difference between mandatory and permissive exclusions?

Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals/entities convicted of the following types of criminal offenses:

Medicare or Medicaid fraud, as well as any other offenses 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 health care-related fraud, theft, or other financial misconduct;
and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

Permissive exclusions: OIG has 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;
and controlling a sanctioned entity as an owner, officer, or managing employee.

How long are individuals/entities on the exclusion list?

For a mandatory exclusion, there is a minimum of 5 years on the exclusion list.

For permissive exclusions, there is a maximum of 0-3 years.

TMC can handle exclusion screening for you

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