OIG Exclusion

also known as: HHS-OIG exclusion · federal healthcare exclusion

An OIG exclusion is a sanction imposed by the Office of Inspector General of the U.S. Department of Health and Human Services (HHS-OIG) that bars an individual or entity from participating in Medicare, Medicaid, and all other federal healthcare programs. When a provider is excluded, no federal healthcare program will pay for any items or services that the excluded person furnishes, orders, or prescribes — directly or indirectly. Employing or contracting with an excluded individual can expose an organization to Civil Monetary Penalties (CMPs) of up to $20,000+ per item or service, plus treble damages. Exclusions fall into two categories. Mandatory exclusions (authorized under 42 U.S.C. § 1320a-7(a)) are required by law — for example, conviction of program-related fraud or patient abuse. Permissive exclusions (§ 1320a-7(b)) are discretionary — for example, license revocation or default on a health education loan. Because the consequences are severe, federal guidance directs healthcare employers and providers to screen every employee, contractor, and vendor against the OIG exclusion list (the LEIE) before hire and on a monthly recurring basis.

A physician convicted of Medicare billing fraud receives a mandatory OIG exclusion under 1128(a)(1); Medicare will not pay any claim they order or prescribe until they are reinstated.

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