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What Causes Exclusion?

As outlined in the Code of Federal Regulations, the OIG may exclude an individual from participation in federal and state health care programs for a variety of offenses. Mandatory and permissive exclusions are as follows:

Mandatory Exclusions (no less than 5 years)

• Conviction of healthcare program-related crimes
• Conviction relating to patient abuse
• Felony conviction relating to health care fraud
• Felony conviction relating to controlled substance

Permissive Exclusions (period varies according to nature of offense)

• Conviction relating to fraud
• Conviction relating to obstruction of an investigation or audit
• Misdemeanor conviction relating to controlled substance
• Healthcare license revocation or suspension
• Exclusion/suspension under a federal or state health care program
• Claims for excessive charges or unnecessary services, and failure to furnish medically necessary services
• Fraud, kickbacks, and other prohibited activities
• Entities controlled by a sanctioned individual
• Failure to disclose required information
• Failure to supply information on subcontractors and suppliers
• Failure to supply payment information
• Failure to grant immediate access
• Failure to take corrective action
• Default on health education loan or scholarship obligations
• Individuals controlling a sanctioned entity

Health care institutions are expected to perform sanction screenings on at least an annual basis for their employees, both current and new hires. Any vendor organizations that provide services to the health care institutions must also be screened, not only for exclusion of those entities, but for exclusion of any individual employees working for the vendors. As stated in multiple places in the regulations, the OIG has the ability to sanction an individual on the basis of whether the person “knows or should know” of the actions constituting the basis for the exclusion.

To support health care organizations in their compliance efforts, various federal and state organizations provide online, searchable databases and updated database downloads, including:

• U.S. Department of Health and Human Services Office of the Inspector General (OIG) List of Excluded Individuals and Entities (LEIE)
• the United States General Services Administration (GSA) List of Parties Excluded from Federal Procurement & Non-procurement Programs (EPLS)
• the Office of Foreign Assets Control (OFAC) Specially Designated Nationals (SDN) List
• Individual State exclusion databases (nine states have individual OMIG offices)