Management, Legal, and Compliance review many issues when a healthcare provider
plans to enter into an agreement. When the
other party is another healthcare provider,
one important consideration is whether the
Department of Health and Human Services
Office of Inspector General (OIG) has
excluded that other party from fed-
eral programs. Such an exclusion is a
penalty imposed by the government
on those who have engaged in fraud,
abuse, or other misconduct related
to a federal healthcare program, not
a voluntary decision by individuals
who have decided not to enroll or to
participate in federal programs.
The OIG has the authority to exclude
individuals or entities under Title XI of the
Social Security Act.1 That exclusion applies
to all federal healthcare programs, includ-
ing Medicare, Medicaid, and other programs
that provide health benefits that the United
States funds either directly or indirect-
ly. 2 If a healthcare provider enters into an
agreement with or employs another who
has been excluded from a federal healthcare
program, the OIG may impose significant
civil monetary penalties or even exclude that
healthcare provider from future participa-
tion. The standard is whether the healthcare
provider knew or should have known that
the party it contracted with was excluded.
Under the exclusion power, the OIG can
mandate that no payment will be made by
any federal healthcare program for any items
or services furnished, ordered, or prescribed
by an excluded individual or entity. This
prohibition covers the excluded party along
with any entity that employs the excluded
party, any hospital at which the excluded
party provides services, or anyone else with
whom the excluded party contracts. Further,
the exclusion applies regardless of how the
claim is submitted or who submits it, and it
applies to all administrative and management services as well.
The exclusionary period is a minimum
of five years, but can be longer. There is an
administrative process in which a notice
of intent to exclude is sent. The process
includes an appeal to an Administrative
by Andrew T. Wampler
Making the search
» Penalties for contracting with excluded parties can be severe.
» Excluded parties are identified in a database called the List of Excluded Individuals and Entities (LEIE).
» Searches for excluded parties are critical during contracting.
» Providers should verify the results of all LEIE searches.
» Providers should document and maintain all exclusion searches.
Andrew T. Wampler (awampler@ wwmgs.com) is a Shareholder at Wilson
Worley PC in Kingsport, TN.