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Medicare and Medicaid Exclusion Lists (OIG and SAM checks).

Some of the most frequent questions we receive at HCL involve checking Medicare and Medicaid exclusion lists.

Agencies want to be compliant with both federal and state regulations, but often the resources for these areas can be somewhat confusing. In this post, we explain what these types of checks are and what is required of agencies.

What are exclusion lists?

Exclusion lists are databases that are maintained by either the federal or state government. These lists contain the names of individuals and entities that are prohibited from receiving federal and/or state funds, specifically the Medicare and Medicaid programs. Any agency that participates in the Medicare or Medicaid program has an obligation to not do business with anyone on the exclusion list. Otherwise, the agency could be subject to penalties, fines, or even exclusion from the Medicare or Medicaid program themselves.

The federal exclusion lists are databases that are maintained by the United States government. The individuals and entities in this database have been convicted of certain offenses (i.e., fraud, patient abuse, felony convictions) and are no longer allowed to receive payments or benefits from the government programs. Any provider, including home health and hospice agencies, that receives federal Medicare or Medicaid funds should check these exclusion lists to ensure that they are not employing or contracting with individuals or entities in the database.

There are 2 primary exclusion lists:

1. Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) – This list is maintained by the OIG and contains names of individuals and entities that have been convicted of healthcare-related crimes.
2. General Services Administration (GSA) System for Award Management (SAM) Exclusion List – This list is maintained by the General Services Administration and contains names of individual and entities that are not permitted to participate in federal programs due to various reasons unrelated to healthcare (i.e., defaulting on federal loans)

Individual states may also have exclusion lists that are maintained by the state. These lists may contain individuals or entities that have been prohibited from participation in the Medicaid or state benefit programs. Some of these actions causing exclusion can include state program fraud, adverse actions by a licensing board such as the state Board of Nursing or Medical Board, or being excluded from the Medicare program. Check your state’s Health and Human Services department for requirements.

While these lists may have some overlap, no one list is all encompassing. Agencies should be diligent in checking all applicable exclusion lists to avoid penalties.

How often should agencies be checking the lists?

State laws can vary and there are no federal regulatory specifics on how often an agency must do these checks. However, an agency that is found employing or contracting with an individual or contractor on any of the exclusion lists would be subject to consequences. For this reason, every agency should have a policy on how often these checks are to be completed and documented. At the very least, a certified agency should be checking the OIG LEIE and GSA SAM lists before hiring or contracting with an individual or entity and also periodically (for example, annually, unless directed by state regulation or accrediting organization standards to complete more often).

Some states, like Texas, have more specific recommendations under their Medicaid program. All states receive some Medicaid funding from the federal government and also contribute additional state funds to their state’s Medicaid program. For this reason, there can be additional requirements including state exclusion lists and frequencies of checks.

Agencies that perform these checks should maintain documentation to verify compliance with the search and reporting requirements.

What else do I need to know about exclusion lists?

Your policies should reflect the regulatory requirements and should show how you are ensuring that employees and contractors are not on the exclusion lists. Your QAPI program should also include personnel record reviews that verify that these checks are being done per policy. If your agency needs assistance with any of these items, HCL is here to help!

Important information for agencies:

Certified home health and hospice agencies:

Certified agencies should check the federal OIG LEIE and GSA SAM exclusion lists on employees and contractors at least before hire and periodically after that (determined by agency policy).  

Federal OIG LEIE check: https://exclusions.oig.hhs.gov/

Federal GSA SAM check:   https://sam.gov/content/home

Texas agencies including PAS:

Any agency that participates in a Texas Medicaid program must check the Texas OIG exclusion list monthly on employees and contractors.

Texas OIG check: https://oig.hhs.texas.gov/exclusions