What is the OIG Exclusion List, and How Could it Affect Your Practice? | ThriveAP

By Healthcare Attorney Alex Scarbrough Fisher

The Office of the Inspector General (OIG) of the U.S. Department of Health & Human Services maintains a list of healthcare providers who are excluded from participating in Medicare, Medicaid, and all other Federal health care programs. This list is known as the “List of Excluded Individuals/Entities (LEIE)” and it is a BIG DEAL for the healthcare providers who unfortunately find themselves on this list. 

Inclusion on the list seriously prohibits a provider’s ability to treat patients, as well as their ability to obtain employment opportunities. For what actions or events will a healthcare provider find themselves on the OIG Exclusion List?

Permissive Exclusions

The OIG has discretionary authority to exclude individuals and entities for the following reasons:

• Misdemeanor convictions related to fraud or the obstruction of an investigation or audit;
• Misdemeanor convictions related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
• The suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence or financial integrity;
• A provider’s exclusion or suspension under Federal or State health care programs;
• The submission of false or fraudulent claims to a Federal health care program by the provider;
• A provider’s default on health education loans or scholarship obligations; or
• A provider’s role in controlling a sanctioned entity as a manager, officer or owner.

Mandatory Exclusions

The OIG is required by law to exclude individuals and entities for the following reasons:

• Conviction of Medicare or Medicaid fraud;
• Patient abuse or neglect;
• Felony convictions for other health care-related fraud, theft, or other financial misconduct; or
• Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

For a complete list, and more details about permissive and mandatory exclusions, see 42 U.S.C.A. § 1320a-7. For more information about the OIG Exclusion list, visit the Office of Inspector General’s website here.

Bottom Line

For physicians, nurse practitioners, and other health care providers facing disciplinary charges by their state medical or nursing board, or those healthcare providers facing potential criminal charges, it is important to know that licensure discipline and criminal charges, among other things, could land a provider on the OIG Exclusion list, and lead to an even steeper uphill battle back to the practice of medicine or nursing.

For employers, it is important to know that an entity can face severe penalties for attempts to recover payment from the federal government for patient care performed by an individual on the OIG exclusion list. I recommend that employers check the Exclusions Database prior to hiring new health care providers to determine if potential hires fall on this list, and to avoid potential liability for the organization.

If a provider is currently on the OIG exclusion list, he or she can apply for reinstatement to participate in Federal health programs once the specified period of exclusion ends. To apply for reinstatement, follow the instructions found here.

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.