OIG Exclusions: what are they and how do they affect your medical practice?

Hiring a healthcare provider can be great for your organization, but if they don’t disclose prior offenses on their record, it could pose a serious risk to your medical practice. That’s why it’s vital to understand the Office of Inspector General (OIG) exclusions and have established vetting procedures during the hiring process.

OIC exclusions for medical providers

The OIG plays an important role in upholding the integrity of the healthcare industry and keeping doctors accountable for honoring their Hippocratic Oath. Because of this, the OIG has set standards and the ability to exclude individuals, entities or businesses from any Federally Funded Health Care program if those regulations are broken.

The OIG maintains an online and free database known as the List of Excluded Individuals/Entities (LEIE). This library of excluded individuals can be searched once a provider is hired. It contains information about anyone who may be providing services for any Federally Funded Health Care program. Because the database is regularly updated, it is crucial not only to search potential employees but once hired, it should also be checked at least every 90 days of continued employment.

There are two main types of OIG exclusions: mandatory and permissive. It is important to understand both types of exclusions and what each means for your practice.

Mandatory exclusions

Mandatory exclusions the more serious of the two. If a provider has this on their record, healthcare organizations are required by law to exclude them from participation. A mandatory exclusion will show up if they have committed any of the following criminal offenses:

  • Medicare or Medicaid fraud

  • Patient abuse or neglect

  • Felony conviction resulting from any other type of healthcare-related fraud

  • Theft or financial misconduct

  • Felony convictions for unlawful manufacturing, distributing, prescriptions or other controlled substances.

If hired, a provider on this exclusion list can make a major impact on the financial health of your practice. In most cases, this will affect the payment of all services and are not reimbursable under Federal health care programs.

Permissive exclusions

Although still serious, permissive exclusions are the lesser of the two. With these types of exclusions, OIG reserves the right to omit any provider or entity on a number of grounds. Some examples of these offenses include but, are not limited to:

  • Misdemeanor conviction relating to healthcare fraud of any Medicare or State health program

  • Misdemeanor from unlawful manufacturing, distributing, prescriptions or other controlled substances

  • Suspension, revocation or surrender of a professional license to provide healthcare

  • The default of health education loans or scholarships

  • Controlling a sanctioned entity as an owner, officer, or managing employee

Ultimately, it’s important to be in the know and ahead of any potential action that could affect your practice if any individual included on the LEIE is hired.

Ensure your organization has a formal and regular process for checking these lists so that your practice remains compliant, you continue getting paid and your providers are giving the best patient care possible.

If you’re looking for help navigating through OIG exclusions or have other credentialing questions, feel free to reach out! Our credentialing experts know this stuff like the back of their hands and are more than happy to help.