Exclusion Statute [Healthcare Compliance Tips]

Discuss the Exclusion Statute with your management team.  And, check the exclusion list (LEIE) at least monthly.

What is the Exclusion Statute?

Per the OIG, under the Exclusion Statute, they have the authority to exclude individuals and entities from Federally funded health care programs.

When the individual or entity is excluded, this means they can no longer receive payments from any federal government programs for any items or services they furnish, order, or prescribe.

What are mandatory exclusions?

The following are considered mandatory exclusions under this statute:

• Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid.

• Patient abuse or neglect.

• Felony convictions for other health care-related fraud, theft, or other financial misconduct

• Felony convictions for unlawful manufacture, distribution, prescription, or dispensing controlled substances

What qualifies as a permissive exclusion?

The following are considered permissive exclusions (but not limited to) under this statute:

• 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; and
• defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee.

Where do I find the List of Excluded Individuals/Entities (LEIE)?

As stated in our previous tip, the OIG suggests that healthcare entities conduct monthly (routine) checks to ensure all current and new employees are not listed on the OIG, GSA, or state lists. And, they emphasize anyone who hires an individual or entity on the exclusion list (LEIE) may be subject to civil monetary penalties (CMP).

Since this process is time-consuming, hiring vendors to complete the screening is your best option.  But, if you still want to oversee this process, you can start by reviewing the OIG’s “Exclusions Program” on their website.

 **The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.