The List of Excluded Individuals/Entities
Your practice may be doing everything it possibly can to code/bill compliantly and stay off the OIG*, CERT*, RAC*. MAC* and anyone else’s list of “bad” actors. However, if you inadvertently hire a clinician who has been excluded from participating in a federal health care program, you may be subject to civil monetary penalties (CMP). And, if a current member of your practice has been excluded, you may also be liable. These liabilities and penalties can apply even if you were not aware of the exclusion. This Timely Topic will provide an overview of the List of Excluded Individuals/Entities (LEIE) listings to help inform you on:
- What actions can result in becoming classified as an excluded clinician?
- Where you can check to make sure all current and potential members of your practice are not on this list.
- A definition of the acronyms used in this article and websites where you can learn more about these programs and parties.
The US Department of Health and Human Services Office of Inspector General (HHS OIG) may exclude a healthcare professional or entity from participation in the Medicare, Medicaid or other federally funded health care program under authority granted to HHS in the Social Security Act. Exclusions may be mandatory or permissive.
Conviction for Medicare or Medicaid fraud, patient abuse/neglect, or unlawful prescribing or dispensing of controlled substances at the felony level are examples of actions that result in mandatory exclusion. Exclusion is required by law.
The OIG has some level of discretion in other circumstances. Examples here would include misdemeanor convictions for prescribing or dispensing controlled substances, revocation/surrender of license to provide care for professional competence or professional performance issues, and participation in kickback arrangements that are not lawful. Defaulting on a health education loan could trigger exclusion.
While a practice could be subject to CMP when it has an employee on the LEIE, the more immediate result is that it will not receive payment for services this employee provides to patients in a federally funded program (to include Medicare and Medicaid).
The OIG maintains the LEIE and updates it monthly. You can keep current on revisions by subscribing to updates from the OIG The LEIE database is publicly available. A search function by which you can look for specific individuals or entities is also provided. It is recommended that you check the list on a routine basis.
*Acronyms and Resources
OIG Office of Inspector General https://oig.hhs.gov/
CERT Comprehensive Error Rate Testing https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT
RAC Recovery Audit Program https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program
MAC Medicare Administrative Contractor https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC