Since 1977, the federal government has provided a list of providers who are excluded from receiving payments from the federal government for committing certain violations. In its current form, this database is known as the List of Excluded Individuals/Entities (LEIE) and is managed by the Office of the Inspector General (OIG) at Health and Human Services (HHS).
The LEIE is a crucial part of compliance for health care organizations. However, the OIG does not issue warnings or send out notifications about excluded providers. It is incumbent upon organizations to search the database regularly to confirm that their practitioners or potential new hires are not on it.
Here is why the LEIE is important to health care providers, the effects of exclusions on entities, individuals, and organizations, what exceptions apply, and how Verisys uses the LEIE as a part of a comprehensive compliance program to protect your organization from monetary and reputational liability.
What is the LEIE and why is searching the LEIE important?
According to the OIG, the List of Excluded Individuals/Entities (LEIE) “provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs.” Individuals and entities are removed from the list after they have been reinstated.
Searching the LEIE is simple; the downloadable or searchable database is updated monthly on the OIG’s website. The OIG’s website also includes a bulletin that gives guidance to providers on the scope and effect of an exclusion and payment prohibition, best practices for searching the LEIE for potential new hires and current employees and contractors, and how to self-disclose the employment or contracting of an excluded person.
The most important reason for searching the LEIE is to ensure that potential hires and current employees are not on the list. Entities or individuals on the LEIE are subject to certain civil and monetary penalties (CMP) and hiring or retaining someone on the LEIE could subject the organization to these CMPs. Providers may be subject to CMP if they submit a claim to a federal health care program either directly or indirectly.
Additionally, many providers who are on the LEIE have committed some sort of fraud, patient abuse or neglect, had a felony conviction for controlled substances, or other serious offenses. Having these providers on staff poses a serious risk to current patients and a liability to the entire organization.
What are the effects of exclusion?
The OIG enacts two types of exclusions: mandatory and permissive. Mandatory exclusions are enforced by law and require the OIG to exclude an individual or entity when they are convicted for committing felony crimes — Medicare or Medicaid fraud, or other felony offenses related to state or federal health care programs; felony convictions related to controlled substances; or convictions for patient neglect or abuse. Permissive exclusions give the OIG discretion over exclusions. The offenses for permissive exclusions are on a misdemeanor level.
The most basic effect of an exclusion is the denial of payments by a federal health care program. This includes “any items or services furnished, ordered or prescribed by an excluded individual or entity.” And this prohibition extends to the excluded person, the employer or anyone who employs or contracts them, including a hospital or other provider, regardless of who submits the claims.
Are there exceptions?
The OIG grants limited exceptions. The special bulletin mentioned previously provides guidance for organizations that would like to hire or employ providers who are on the exclusion list.
Those exceptions include federal health care programs that “do not pay, directly or indirectly, for the items or services being provided by the excluded individual,” and providers who furnish items or services specifically to non-federal health care program beneficiaries. Essentially, so long as a provider does not render services or items to a federal health care program and the funds do not overlap, they can be employed without being subject to CMPs.
This can be a tricky landscape to navigate, so special precautions should be taken when working with excluded entities and providers.
The OIG also has the ability to waive an individual or entity’s exclusion. According to the OIG:
An individual or entity excluded under sections 1128(a)(1), (a)(3) or (a)(4) of the Act may be eligible for a waiver only when the excluded individual or entity is the sole community physician or the sole source of essential specialized services in a community AND the exclusion would impose a hardship on beneficiaries (as defined in section 1128A(i)(5) of the Act) of that program. An individual or entity excluded under section 1128(a)(2) of the Act as a result of a conviction related to patient abuse or neglect is not eligible for a waiver. See 42 CFR 1001.1801(a)-(b).
Only an administrator of a federal health care program can request a waiver. A provider or entity cannot request a waiver for themselves. The OIG also lists the waivers currently in force as well as a letter outlining the scope for the waivers on their website.
Employing or contracting with an individual or entity on the LEIE can hold serious risks — in both money and reputation — for an organization and the patients they serve. Searching the LEIE database isn’t a one-time task and should be continually monitored and tracked to ensure compliance.
Verisys offers the most comprehensive data set for screening and monitoring health care providers with continuous updates. Verisys’ teams pull data from more than 5,000 data sources, adding roughly 75,000 records to their database monthly. With one login, an organization can automate continuous monitoring and set alerts to receive notice of adverse action affecting one of your providers.
And while the OIG exclusion list is important, it is not a comprehensive solution to searching for fraudulent, abusive, and risky providers. Verisys checks thousands of additional data sources to protect your organization from financial and reputational risk and increase patient safety.
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 | Written by Heather Lynn Gillman Director of Healthcare Communications |
