Exclusion monitoring is a critical tool for ensuring compliance, program integrity, and patient safety. Healthcare organizations can't afford not to monitor their populations for exclusions, however, because there are several lists at both the federal and state levels that need to be continuously monitored, exclusion monitoring can be complicated. Read on for a summary of exclusion monitoring sources as well as some other eligibility-affecting databases. To learn more, check out ProviderTrust's blog post on the topic.
Federal Exclusion Sources
The two major federal sources that need to be screened for exclusions at a minimum monthly are the Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) and SAM.gov.
The OIG LEIE consists of individuals and entities that have been excluded from participating in federal healthcare programs. Indirect and direct federal reimbursement for goods provided or services rendered by an excluded individual or entity is prohibited. This includes reimbursement for salaries, benefits, or items claimed/billed by licensed healthcare providers or administrative personnel. Also, healthcare organizations cannot purchase goods or services from excluded entities and vendors.
Want to learn more about OIG exclusion list monitoring? Check out our blog post.
The SAM.gov database is formerly known as the Government Services Administration's (GSA) Excluded Parties List System (EPLS). In 2012, the GSA announced it was migrating data from the EPLS to a new and more comprehensive system called the System for Award Management (SAM). Formed under a mandate of the Affordable Care Act, SAM.gov created one broader dataset of individuals and entities that are debarred, sanctioned, or excluded from doing business under a federal contract. The most significant database for healthcare providers, SAM.gov includes several federal contracting databases such as USDA-FNS, TREAS-OFAC, OPM, and more. SAM.gov datasets should be included in all exclusion screening processes for employed and contracted populations
State Medicaid Exclusion Lists
In addition to the federal exclusion lists, state Medicaid lists must also be monitored. State Medicaid exclusion sources present significant challenges to manual screening processes. They publish exclusion records in different formats and with varying amounts of data, making it difficult and resource-intensive to identify a match within your population. As of July 2021, there are 42 state Medicaid exclusion lists published and maintained.
It's vital to check every available state Medicaid exclusion source to ensure compliance across your operations and populations (providers, employees, licensed staff, vendors, and volunteers) and to effectively reduce your organization's risk. And because 50% of all state Medicaid exclusions never show up on the OIG LEIE.
As of July 2021:
- The OIG LEIE has more than 74k excluded individuals and entities.
- The SAM.gov database has more than 70k excluded individuals and entities.
- State Medicaid lists include more than 73k excluded individuals and entities.
To explore an interactive map of healthcare exclusions across the U.S., click here.
Additional Eligibility-Affecting Sources
- OFAC: The Specially Designated Nationals and Blocked Persons List (SDN) and the consolidated sanctions list, as well as other sanction lists are published by OFAC. While OFAC is not specifically concerned with healthcare, many organizations choose to incorporate these sources in their monitoring programs.
- SSA DMF: The Death Master File (DMF) from the Social Security Administration (SSA) contains more than 85 million records of deaths that have been reported to SSA. Many healthcare organizations include SSA DMF monitoring alongside their exclusion and license monitoring to guard against identity theft and fraud.
- Medicare Opt Out: This list includes physicians and practitioners who don't wish to enroll in the Medicare program. It's important that healthcare organizations don't include any of these individuals in billing to avoid errors and claims that cannot be processed.
For an in-depth look into all exclusion authorities, check out our Guide to Healthcare Exclusion Authorities.