The OIG list of excluded parties and entities


How and why does it matter to you?

CarolinaFireJournal - Kathryn D. Gailey, JD, MPH
Kathryn D. Gailey, JD, MPH
10/10/2014 -

In the world of healthcare compliance, the Office of Inspector General (OIG) exclusions are a hot topic, yet many people still do not know what this list is and how to use it. So for starters, does it apply to your emergency service department or squad? If you receive federal health care program funds, then yes it does is the short answer, but there is more you will need to know.

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The Office of the Inspector General’s (OIG) List of Excluded Individuals/Entities (LEIE) is a list of individuals and entities that are currently excluded from participation in Medicare, Medicaid, Tricare, VA programs, SCHIP and other programs funded in whole or in part by the Federal government.

What is the Exclusion List

The Office of the Inspector General’s (OIG) List of Excluded Individuals/Entities (LEIE) is a list of individuals and entities that are currently excluded from participation in Medicare, Medicaid, Tricare, VA programs, SCHIP and other programs funded in whole or in part by the Federal government. The individuals/entities excluded from participation in federal health care programs are those convicted of program-related crimes. Mandatory and permissive exclusions are related to certain program-related crimes and require certain time frames for exclusions or possibly a permanent exclusion.

Process for Exclusion

The OIG provides notice of intent to exclude and the OIG considers materials provided by the entity or individual who received the notice and then the OIG makes a decision. This decision may be appealed to the Health and Human Services Administrative Law Judge, the Health and Human Services Department Appeals Board, or judicial review in Federal court.

Effect of Exclusion

Once exclusion is in place, no federal health care payment may be made for items or services provided by an excluded person or at the direction or order of an excluded person. Keep in mind that it is not just providers.“Also, excluded individuals are even prohibited from providing transportations services that are paid for by a federal health care program, such as those provided by ambulance drivers or ambulance company dispatchers.” (May 8, 2013 OIG Updated Special Advisory Bulletin) Furthermore, exclusions do not just involve being prohibited from providing patient care, those excluded individuals or entities may not provide administrative services, health information technology and support, strategic planning, billing and accounting, staff training, human resources, nor can they serve in executive or leadership roles.

Sanctions and Penalties

The sanctions and penalties are stiff and some departments have found out the hard way just how stiff they truly are. You can receive sanctions and penalties for:

  1. Submitting claims to Federal programs while you are an excluded individual or entity
  2. If you prescribe or order items or series while you are excluded if paid by federal programs
  3. If you employ a person that is an excluded individual or you contract with an excluded individual or entity. Penalties are $10,000 for each item or service claimed that was provided during a period a person was excluded and can be up to three times the amount of the claim.

To show the extent of such penalties, there was a North Carolina EMS agency that had a person working on their staff that was on the excluded list and when the OIG came in, they lost all funding for every call that person responded to during the time period that person was on the excluded list.

Screening for Exclusions

“The Balanced Budget Act (BAA) authorized the imposition of civil monetary penalties (CMP) against providers that employ or enter into contracts with excluded persons to provide items or services payable by federal health care programs.” Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, Issued May 8, 2013. The imposition of CMPs against providers that employ or enter into contracts with excluded persons to provide items or services payable by federal health care programs highlights the importance of checking not only all of your employees/volunteers, but also those with whom you enter contracts.

Providers should check the OIG LEIE prior to employing or contracting with persons/entities and then periodically to determine the current exclusion status. While providers are not required by statute or regulation to check the LEIE, it is left up to providers to decide how frequently to check the LEIE. The LEIE is updated on a monthly basis, so the recommendation is to check employees and contractors each month in order to minimize potential payment. The Centers for Medicare and Medicaid Services (CMS) has recommended that states consider making this a requirement for all providers and contractors, including managed care entities so you will need to check with your specific state requirements to ensure you are in compliance.

This is a huge deal and sometimes we at MSFES feel in our opinion, that the federal and state government turns a blind eye to issues related to the emergency services, but we are quickly seeing that the OIG takes this issue very seriously and departments that you may know have been the subject of sanctions and penalties. Please know that this article highlights the basics but this is by no means all-inclusive.

MSFES is a team of retired fire chiefs, licensed attorneys and CPAs that have teamed together to provide emergency service departments and squads with administrative risk reduction services that once only big companies and departments could afford. Working with and endorsed by VFIS, MSFES is bringing those services to any department, big or small, for the lowest prices possible, to help reduce the legal and day-to-day administrative risks faced by and placed upon today’s departments. MSFES may be reached at: www.msfes.net or call (828) 409-1638 for help on understanding the legalities related to the OIG. Our Human Resources personnel & attorneys will help you through the procedures.

Kathryn D. Gaileyis general counsel for Management Solutions for Emergency Services, LLC.

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