NY State Medicaid Sanctions: OMIG Exclusions, Penalties, and How to Check the List

Overview of OMIG Medicaid Exclusion List

What the list is and why it exists

The New York State Office of the Medicaid Inspector General (OMIG) maintains the Medicaid Exclusion List to protect NYS Medicaid Program Integrity. It identifies individuals and entities that are excluded, terminated, or otherwise restricted from participation in the New York Medicaid program due to unacceptable practices, fraud, abuse, or other sanctionable conduct.

The list is a core tool for provider sanction enforcement. It supports Medicaid Fraud Investigations and administrative actions by flagging parties that cannot bill, order, prescribe, or oversee services paid by Medicaid in New York.

Who appears on the list

• Licensed professionals (e.g., physicians, pharmacists, therapists) and unlicensed staff whose conduct affects Medicaid claims.
• Facilities and supplier businesses, including owners, managers, or responsible individuals associated with the entity.
• Affiliates tied to excluded parties, when OMIG determines their involvement threatens program integrity.

How it differs from federal databases

OMIG’s Medicaid Exclusion List is state-specific and separate from the federal OIG List of Excluded Individuals/Entities. Providers should screen against both because state exclusions, federal exclusions, or both may apply. New York exclusions are administered by OMIG’s Administrative Remedies Unit, which issues, tracks, and enforces state-level actions.

Consequences of Employing Excluded Individuals

Impact on claims and participation

Hiring or contracting with an excluded person or company can trigger automatic overpayments: any item or service furnished, ordered, supervised, or supplied—directly or indirectly—by an excluded party is not payable by Medicaid. Resulting claims can be denied or recouped in full, and related provider enrollment may be restricted or terminated.

Operational and reputational risks

• Repayment obligations and withholds that disrupt cash flow and operations.
• Exclusion penalties, including additional assessments and interest, based on the scope and duration of the violation.
• Expanded reviews, audits, or Medicaid Fraud Investigations that consume staff time and external costs.
• Mandatory corrective actions and heightened monitoring that affect contracts with managed care plans and referral sources.

Compliance expectations

OMIG expects robust screening protocols at onboarding and throughout employment or contracting. You should prevent excluded individuals from roles that influence Medicaid services or claims (including administrative, leadership, or billing functions), and you must document screening and decision-making to demonstrate effective OMIG Compliance Program controls.

Monetary Penalties and Compliance Requirements

Financial exposure

OMIG may impose civil monetary penalties, assessments per affected claim or service, interest on overpayments, and other administrative remedies. Penalty amounts can escalate based on repeat violations, failure to cooperate, or concealment. Self-disclosure and prompt corrective action can mitigate penalty exposure.

Core elements of an effective OMIG Compliance Program

• Written policies and procedures tailored to your risk areas, including vendor and workforce exclusion screening.
• A designated compliance officer and governance oversight that receive regular reports on program effectiveness.
• Training and education for employees, contractors, and medical staff on exclusion rules and reporting channels.
• Routine auditing and monitoring, including documented screening of the Medicaid Exclusion List and federal databases.
• Processes for responding to suspected violations, timely repayment of overpayments, and corrective action tracking.
• Disciplinary standards for noncompliance and documentation retention that substantiates due diligence.

Required providers must meet OMIG’s compliance standards and, where applicable, complete annual certifications or surveys. Strong documentation of screening frequency, match resolution, and outcomes is a key safeguard during provider sanction enforcement reviews.

How to Access and Use the OMIG Search Tool

Step-by-step screening workflow

1. Navigate to OMIG’s exclusions search page from the official OMIG website.
2. Select whether you are searching for an individual or an entity.
3. Enter identifying information (e.g., full legal name, known aliases, license or certificate number, and—for entities—FEIN or DBA). Use exact spelling, then try variations.
4. Review results carefully: match on multiple identifiers (date of birth, license number, address history) to confirm true positives and avoid false matches.
5. Open detailed result records to note status, effective dates, reason codes, and any reinstatement information.
6. Document your screening: capture a date-stamped result (e.g., PDF or screenshot), store it in a centralized log, and record any resolution steps for potential matches.

Programmatic and ongoing monitoring

• Screen at onboarding, prior to assignment changes, and on a recurring cadence (commonly monthly) for all employees, contractors, referring providers, and key vendors.
• Cross-check the federal OIG database and any other payer-required lists as part of a comprehensive exclusion screening protocol.
• Escalate ambiguous results to your compliance officer and, when needed, consult OMIG’s Administrative Remedies Unit for clarification.

Recent Exclusions and the OMIG Short List

How the Short List complements the full database

The OMIG Short List highlights recent exclusions and reinstatements so you can quickly update your rosters without waiting for periodic data refreshes. It is a practical tool for day-to-day NY State Medicaid sanctions monitoring and helps you prioritize new risk entries.

Best practices for using recent updates

• Incorporate Short List checks into your monthly screening cycle and reconcile any hits against your active workforce and vendor files.
• Confirm each apparent match in the full Medicaid Exclusion List and document the effective date before taking action.
• If you discover a historical gap (e.g., services billed while a person was excluded), initiate a root-cause review and consider self-disclosure.

Contacting OMIG for Assistance

When to reach out

• You need help confirming whether a potential match is the same person or entity.
• You received a notice related to provider sanction enforcement or a recoupment and require clarification.
• You seek guidance on reinstatement eligibility or documentation requirements.
• You plan to appeal an exclusion or respond to correspondence from the Administrative Remedies Unit.

Information to gather before contacting OMIG

• Complete legal name, aliases, license or certificate numbers, NPI (if applicable), date of birth for individuals, and FEIN for entities.
• Addresses, employment or contract history, and the timeframe of potential Medicaid involvement.
• Copies of search results, internal screening logs, and any prior communications with OMIG.

Summary: By operationalizing rigorous screening, documenting decisions, and engaging OMIG promptly when issues arise, you can reduce the risk of exclusion penalties, protect reimbursements, and demonstrate strong NYS Medicaid Program Integrity across your organization.

FAQs.

What are the penalties for employing excluded Medicaid providers?

Expect repayment of all Medicaid funds tied to items or services furnished—directly or indirectly—by the excluded party, denial of pending claims, and civil monetary penalties with interest. Additional consequences can include enrollment actions (e.g., restrictions or termination), corrective action plans, and intensified oversight by OMIG.

How can providers verify exclusion status on the OMIG list?

Use the OMIG exclusions search tool to look up individuals and entities by name and unique identifiers. Match on multiple data points (e.g., license number, date of birth, FEIN) to verify identity, review status and effective dates, and retain a date-stamped copy of your search as proof of screening.

What is the process for appealing an OMIG exclusion?

After OMIG issues notice, you typically have a defined window to respond, submit evidence, and request review through the Administrative Remedies Unit. The process may involve written submissions, production of records, and, where provided by rule, a hearing or reconsideration pathway. Timely, well-documented responses and corrective actions improve outcomes.

How often is the Medicaid Exclusion List updated?

The full Medicaid Exclusion List is updated on an ongoing basis as actions are finalized. OMIG also publishes a Short List that highlights recent additions and reinstatements, typically issued on a periodic (often monthly) basis. Always rely on the most current posting date when screening.