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Don’t Pay the Price for Medicare Exclusions

Making the mistake of employing an excluded physician, nurse, nonphysician provider or administrator will lead to you facing thousands in civil money penalties — not to mention the money you’ll lose for services you’ve provided that can never be billed.

Thinking that this can’t affect your practice is a HUGE mistake. In fact, the Office of Inspector General’s (OIG) website is full of practices that have paid the price of employing excluded providers and administrators. 

Being excluded means that these professionals have been kicked out of federally funded healthcare programs, which includes Medicare and Medicaid, among others. There are two reasons that OIG can use to issue excluded status:

  • Mandatory Exclusions — These are required by law for individuals and organizations convicted of the following types of offenses:
    • Medicare/Medicaid fraud
    • Patient abuse or neglect
    • Felony convictions for other healthcare-related fraud, theft or other financial misconduct
    • Felony convictions related to unlawful manufacture, distribution, prescription or dispensing of controlled substances.
  • Permissive Exclusions — For these, OIG has the discretion — rather than a mandate — to exclude based on a number of grounds:
    • Misdemeanor convictions related to healthcare fraud other than Medicare or a state health program
    • Misdemeanor convictions related to the unlawful manufacture, distribution, prescription or dispensing of controlled substances
    • Suspension, revocation or surrender of a healthcare license related to professional competence, performance or financial integrity
    • Providing unnecessary or substandard services
    • Submitting false or fraudulent healthcare claims
    • Engaging in unlawful kickback arrangements
    • Defaulting on health education loans or scholarship obligations
    • Controlling a sanctioned entity as an owner, officer or managing employee.

To stay out of the OIG’s crosshairs for exclusion violations and penalties, you must routinely check the agency’s List of Excluded Individuals and Entities (LEIE). Hiring a new clinician is a perfect time to do this, and you should also regularly check your existing providers to avoid any nasty surprises, such as denied claims.

You can download the list on the OIG website: And here are a few tips for using it:

  1. Be sure to check both current and former names an individual might use, such as maiden names, previous married names, etc.
  2. If the person has a hyphenated last name, look for all versions — for instance, look for John Jones-Smith as John Jones, John Smith and John Jones-Smith.
  3. Maintain documentation of any names searches you perform to verify results and substantiate your intentions to comply.
  4. You can search up to five names at once using the Online Searchable Database. And if you have a longer list, try the downloadable version because you can use the spreadsheet search function to speed your efforts.
  5. Double-check your spelling during your search.
  6. Try entering only the first few letters of the name in the search field. It will return more accurate results.
  7. Verify any potential matches you find in the downloadable list by entering the individual’s Social Security number in the Online Searchable Database.

If you fail to check this list and one of your providers is on it, not only could you be facing civil money penalties, but you’ll also not receive payment for any services or items furnished, ordered or prescribed by an excluded individual. This leaves you with numbers that can add up fast, especially if the provider is caring for some of your sickest patients.


Take Aways:

  • Check the OIG’s LEIE to make sure none of your potential or current providers are listed.
  • If a candidate physician is on the list, you should reconsider hiring that individual because you won’t be able to bill Medicare or Medicaid for his services.
  • When searching the LEIE, make sure to check all potential versions of a name.
For more information regarding OIG exclusion, check out Coding Leader's online training session on Avoid Medicare Exclusion and Thousands in Lost Payments.  And you can view all upcoming live online training sessions at

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