Medicare Compliance & Reimbursement

Question: Our small practice doesn’t routinely check the HHS Office of Inspector General’s (OIG’s) List of Excluded Individuals/ Entities (LEIE). Is that something we should be doing and how often should we review the list?

Mississippi Subscriber

Answer: Yes, you definitely should be checking the LEIE on a monthly basis, and you should always review it before hiring new employees or enlisting new vendors or contractors.

Here’s why: You run major financial and compliance risks by skipping an exclusions database check. And don’t assume you’re in the clear once an individual’s exclusion period is over.

“Reinstatement of an excluded individual or entity is not automatic once the specified period of exclusion ends,” OIG guidance says. “In order to participate in the Medicare, Medicaid and all Federal health care programs once the term of exclusion ends, the individual or entity must apply for reinstatement and receive written notice from OIG that reinstatement has been granted,” the national watchdog warns.

Consider these two recent examples:

• Digestive Health Associates (DHS) in Reno, Nevada had to pay OIG more than $13,000 for hiring an excluded individual. “OIG’s investigation revealed that the excluded individual, a medical assistant, provided items or services that were billed to federal healthcare programs,” says an OIG notice.
• CareCo Medical and its owner/CEO Helga Pfanner agreed to pay more than $28,000 for employing an individual excluded from all federal healthcare programs. In November 2018, CareCo and Pfanner hired physical therapist Todd Roberts for a management position at the agency. But Roberts had defaulted on a Corporate Integrity Agreement with the OIG and was excluded in 2015. He worked at the Waterford agency until March 2019.

Reminder: The OIG has two categories of exclusions, mandatory and permissive. Though the feds offer definitions for both, much grey area exists. How the OIG determines the severity, circumstances, and content of an exclusion depends on the level of fraud, parties involved, location, and more. In a nutshell, a provider or supplier who commits fraud, while providing services or supplies under one of the federal or state health programs and is proven guilty, can be banned from future participation in the programs.

OIG updates the LEIE monthly and removes individuals from the list once they are reinstated.

Resource: Find the exclusions list at https://oig.hhs.gov/exclusions/exclusions_list.asp.