Call Now (800) 561 - 0798

Medicare Exclusion Checks Will be Audited by OIG

Medicare Exclusion Audit by OIG
By Paul Weidenfeld

In October of 2015, the Department of Health and Human Services, Office of Inspector General (HHS/OIG) issued its Work Plan: Fiscal Year 2016.” The purpose of the Work Plan is to summarize new and ongoing OIG reviews with respect to HHS-programs and operations. Notably, both Medicare Exclusion and Medicaid Exclusion issues will be covered in several investigative and/or audit projects conducted during Fiscal Year 2016.

I. Enrolling and Enrolled Providers will be Checked for OIG Exclusions

Perhaps the most significant project cited in OIG’s 2016 Work Plan is their planned review of agency oversight regarding provider ownership information by state and federal authorities. Additionally, OIG plans to focus on compliance in checking required exclusion databases for enrolling and enrolled providers. As the 2016 Work Plan states:

We will determine the extent to which States collect required ownership information for provider entities enrolled in Medicare and Medicaid, and we will describe the extent to which they verify the collected information. We will also determine whether States and CMS checked exclusions databases for enrolling and enrolled providers, as required. Finally, we will compare the ownership information that selected providers gave to States to enroll in Medicaid, and that providers gave to CMS to enroll in Medicare, to the ownership information that the same providers gave to OIG for the purposes of this study. Federal regulations require Medicaid and Medicare providers to disclose ownership information, such as the name and address of each person and corporation with an ownership or controlling interest in the provider entity.” (See e.g., 42 CFR §4 55.104 and 42 CFR §420.206.)(OEI; 04-11-00590, 04-11-00591; expected issue date: FY 2016)(Emphasis Added).

The focus of this audit by OIG reflects that both the Centers for Medicare and Medicaid Services (CMS) and the state Medicaid authorities are being assessed regarding their thoroughness in conducting required Medicare exclusion and Medicaid exclusion screenings. This includes both newly enrolling and already enrolled health care providers.

II. The Importance of Medicare Exclusion Screening Continues to Rise

OIG’s interest in exclusion enforcement has continued to increase. This increased interest particularly applies to the requirements of exclusion screening to ensure that excluded individuals or entities are not participating in federal or state health benefit programs (such as Medicare and Medicaid). OIG’s planned audit of federal and state exclusion checks regarding enrolling and enrolled health care providers and suppliers is merely the government’s latest efforts in this regard.

III. What are Your Responsibilities with Respect to Medicare Exclusion Screening?

The OIG requires health care providers to perform an exclusion screening by checking a variety of federal Medicare exclusion and state Medicaid exclusion databases. This includes checking any employees, vendors and contractors providing goods or services to these participating providers and suppliers. There are a total of 40 databases that must be checked. These databases include the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), formerly maintained by the General Services Administration (GSA), and 38 state OIG Medicaid exclusion databases.

IV. Conclusion

It is important to understand that each State Medicaid program also has two sets of exclusion screening requirements. These typically include a “basic” screening requirement that includes monthly checks of the State database in addition to the LEIE, and an additional set as part of the enrollment or re-enrollment process. The second set must be checked on a State by State basis, but some, such as the regulations in  New York and Texas, require that participating providers and suppliers certify that that none of their employees, vendors or contractors have been excluded from any State or Federal Health Care Program! Obviously, such a certification can only be accomplished by searching every federal and state exclusion list. This is a task likely to be beyond the ability of any health care provider regardless of size and resources without the assistance of a third party such as Exclusion Screening, LLC


Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime health care lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should you have any questions at: or 1-800-294-0952.

Compliance Hotline