OIG Exclusion Screening: What to Do If a Match Is Found

Verify Identity and Match Accuracy

If LEIE Screening flags a possible match, pause and verify identity before taking action. Start by comparing unique identifiers from the OIG List of Excluded Individuals/Entities to those you have on file.

• Match on multiple data points: full legal name, known aliases, date of birth, NPI, license number, and last four digits of SSN or TIN (where lawfully collected).
• Review address history, prior employers, specialty, and state licensure to rule out common-name collisions.
• Request government-issued identification or corroborating documents from the individual or vendor to confirm details.
• Document why a record is or is not the same person or entity, including screenshots and time-stamped notes.
• When doubt remains, treat the case as unresolved and escalate promptly rather than clearing it prematurely.

Your goal in this step is simple: decide whether the LEIE result truly matches your subject. Accurate identification prevents unnecessary disruption and ensures you address real Federal Healthcare Program Exclusion risk.

Confirm Exclusion Status and Effective Dates

Once you confirm identity, determine whether the exclusion is active and the dates it covers. Note the authority type—Mandatory Exclusion or Permissive Exclusion—and the effective date to understand scope and risk.

• Confirm the current status on the OIG List of Excluded Individuals/Entities and capture the exclusion start date and any reinstatement or end date shown.
• Identify the basis: Mandatory Exclusion generally stems from specified offenses; Permissive Exclusion covers a broader range of conduct. The basis can influence remediation and lookback scope.
• Check for name changes, license actions, or parallel state Medicaid exclusions that may extend operational impact.
• Map the individual’s or vendor’s involvement at your organization against the exclusion period to estimate potential exposure.

If the record shows a prior removal from the LEIE, verify that the reinstatement predates any work they performed for you. Absence from the LEIE is not automatic reinstatement; the person must complete the Reinstatement Process.

Notify Compliance Officer or Legal Department

Initiate a formal Compliance Officer Notification immediately after confirming a likely match. Speed preserves evidence, limits further risk, and coordinates a consistent response.

• Alert your compliance officer and legal department, providing identifiers, match documentation, and a concise timeline.
• Issue a legal hold for relevant emails, contracts, timesheets, referrals, and claims data.
• Direct billing to hold or scrub potentially affected claims while facts are verified.
• Decide interim workforce or vendor status and communication plans to affected managers.
• Set a review cadence so stakeholders track findings, deadlines, and decisions.

Centralized oversight ensures decisions align with policy and preserves privilege where appropriate.

Remove or Refrain from Federal Healthcare Program Participation

Until you resolve the match, remove the individual or entity from activities that generate items or services payable by federal programs. An exclusion bars payment for anything furnished, ordered, or prescribed by the excluded party.

• Cease patient care, ordering, prescribing, referring, billing, coding, utilization review, and any support that contributes to federal claims.
• Disable e-prescribing, ordering privileges, and system access tied to federally reimbursable services.
• For vendors, suspend purchase orders and deliveries that feed into federal program claims.
• Reassign to non-federal, non-claim-supporting duties only if your risk assessment supports it.
• Notify scheduling, pharmacy, lab, and revenue cycle teams so no services slip through to billing.

This step contains exposure while you validate status and determine next actions in line with Federal Healthcare Program Exclusion rules.

Follow Internal Policies for Excluded Individuals

Apply your written policies consistently to employees, contractors, medical staff, and vendors. Clear rules protect patients, ensure fairness, and demonstrate an effective compliance program.

• Follow defined pathways for interim suspension, reassignment, or separation, and ensure HR involvement.
• For vendors, enforce contractual certification of non-exclusion and exercise termination or cure rights when appropriate.
• Escalate material findings to the compliance committee or board per your governance framework.
• Enhance screening frequency for high-risk roles and incorporate pre-hire and ongoing LEIE checks.
• Update training and attestations so workforce members understand exclusion prohibitions and reporting duties.

When policies contemplate self-disclosure or payor notification, coordinate those actions under counsel and keep leadership informed.

Document Actions Taken and Maintain Records

Maintain a complete, contemporaneous record from first alert to final resolution. Thorough documentation supports audits, repayments, and any disclosures you pursue.

• Archive LEIE Screening results, match analysis, and identity corroboration with timestamps.
• Record Compliance Officer Notification, leadership briefings, and legal guidance received.
• Log workforce changes, access removals, claim holds, and any refunds or adjustments.
• Preserve communications with the individual or vendor, including requests for information.
• Compile a closing memo summarizing facts, dates, decisions, and the outcome, including any Reinstatement Process confirmations.
• Retain records per your policy and applicable federal and state requirements.

Good records reduce repeat work, demonstrate diligence to regulators, and speed future audits or investigations.

Understand Consequences of Non-Compliance

Employing or contracting with an excluded party can trigger significant liability. Even indirect contributions to federally reimbursed services can create overpayments and penalties.

• Repayment obligations for claims connected to items or services furnished, ordered, or prescribed by an excluded individual or entity.
• Civil monetary penalties and assessments under exclusion authorities, with potential additional sanctions.
• False Claims Act exposure, potential corporate integrity obligations, and reputational harm.
• Contract termination, credentialing actions, and disruption to clinical operations and revenue cycle.

Prompt, well-documented action limits damage and evidences an effective compliance program.

FAQs.

What steps should be taken after identifying a match on the OIG exclusion list?

Pause participation in federally reimbursable activities, verify identity against LEIE data, confirm exclusion status and dates, issue a Compliance Officer Notification, remove the person or vendor from federal program work, hold related claims, and document every step until you determine final disposition.

How can an organization confirm the accuracy of an exclusion match?

Compare multiple identifiers—legal name, aliases, date of birth, NPI, license numbers, and available SSN/TIN fragments—against the OIG List of Excluded Individuals/Entities. Corroborate with documents from the subject, review address and licensure history, and record why the data supports or rules out a true match.

What are the legal consequences of employing an excluded individual?

Claims tied to items or services furnished, ordered, or prescribed by the excluded person are not payable and may require refunds. Organizations also face civil monetary penalties, potential False Claims Act exposure, contractual and credentialing repercussions, and reputational damage.

How can excluded entities apply for reinstatement?

Exclusion does not end automatically. After the exclusion period, the individual or entity must complete the OIG Reinstatement Process, submitting the required application and documentation. Only upon written confirmation of reinstatement—and verification that the name is absent from the LEIE—should participation in federal healthcare programs resume.