Trust is the foundation of healthcare. Patients place their faith in their healthcare providers to make sure they recover from their illness and the government gives hospitals, physicians, and other healthcare organizations access to taxpayer dollars to help treat patients. The government has created systems to remove bad actors from the healthcare industry in order to maintain trust; one of these government programs uses the Exclusion List OIG to base decisions upon.

If you work in any area of healthcare, whether it be human resources, compliance or billing, then you have likely been exposed to the terms "Exclusion List" and "OIG." But, what do these terms mean? This article will provide a brief overview of both the OIG's exclusion process as well as some tips about how you can help protect your company against individuals who may be in violation of OIG regulations.

What does it mean to be excluded from a program by OIG?

Being excluded from a federal healthcare program is similar to getting sent off the field in soccer.

The Office of Inspector General (OIG) has the power to exclude individuals and organizations from participation in the federal government-funded healthcare programs, such as Medicare and Medicaid. The majority of the time, this exclusion results from a crime.

Examples of offenses that may result in OIG exclusions include:

- Medicare and Medicaid fraud

- Abuse or neglect of patients

- Felony convictions concerning healthcare matters

- Financial fraud

The big difference after an individual is excluded is that there isn't a healthcare provider who can bill the government for any services the excluded individual provides. It doesn't matter if you're a brain surgeon or a janitor; if you have an exclusion, no salary related to that exclusion can involve federal funds.

Why You Should Check the OIG Before Hiring a New Employee

Because the consequences of hiring a person on the OIG Exclusion List are so severe, it is vital that the OIG exclusion database is checked before hiring to ensure that the employee will not provide services to beneficiaries under federal law.

The processes used by the employer to evaluate potential hires will usually involve confirming references and possibly checking criminal backgrounds. However, it is also essential that the employer performs OIG Exclusion checks via a government database as part of the potential employee evaluation process. 

The OIG Exclusion List updates on a continuous basis; therefore, the best practice is to verify OIG checks monthly for all employees. A person who was hired five years ago may have been added to the OIG Exclusion List yesterday and therefore the employer would need to terminate him or her from employment.

When an Employee Is Excluded by OIG What Happens Next?

Suppose you conduct a monthly screening of employees and discover a potential match for exclusion from the OIG excluded list, Discovering that one of your nursing staff has been excluded from the OIG. What should be the next actions?

Initially, you will want to confirm that the individual in question is, in fact, the same individual by doing a verification of the individual with a Social Security number or other identifiers. Once they are validated, you need to take action quickly.

If you employ someone who is excluded by OIG for performing services in a capacity that is billed to federally funded programs, your company is pursuing "false claims" to Medicare in connection with the compensation you have provided to that employee and since these claims are considered "false," businesses can be heavily penalized by the Government due to their actions. You may also be compelled to repay the Government for amounts received as a result of billing for work performed by the excluded employee.

The OIG Check is therefore critical for the continued financial viability of the company.

The terms of an OIG exclusion are not permanent; however, not all OIG exclusions will have the same expiration period (5 or 10 years), and the expiration of an exclusion is not automatic.

In order for the exclusion to be lifted, the individual must submit a request for reinstatement (OIG has to provide a written confirmation of this). If the individual has not received written documentation that they have been reinstated, they will continue to be considered an excluded person. Therefore, when an employee tells you, "I have served my time," you must check their exclusion status against the OIG exclusions list before allowing the employee to work again on federal programs.

OIG Exclusions List Navigation

All of the information contained within this database can be found in the LEIE or the Exclusions List OIG.

It has been established as a public access system to allow anyone to access the database, which lists banned individuals and entities.

The Exclusions List OIG should be considered the foundation upon which an employer will provide a safe working environment for all of its employees.

The use of the Exclusions List OIG may be cumbersome if an employer has a large employee group because it takes a long time to go through the process of putting the employees' names into the system one at a time. Also, if an employer transposes or misspells the name while entering, it is possible to miss the matching name in the Exclusions List OIG's database; therefore, most employers now utilize automated tools to find matches as quickly and accurately as possible.

Summary

Managing compliance can seem like a lot of paperwork, but the logic behind it is simple. The government wants to ensure that federal money doesn't go to people who have proven to be untrustworthy.

By understanding what an OIG Exclusion is and making the OIG Check a regular part of your monthly routine, you protect your organization. It ensures that you are providing safe care and that you won't face surprise fines down the road. Keeping an eye on the Exclusions List OIG is just a standard part of doing good business in the healthcare world.