OIG Background Check: A Complete Guide

Healthcare employers should perform OIG background checks to identify applicants and employees who have been excluded from participating in federal healthcare programs, including Medicare and Medicaid.

Failing to conduct an OIG background check on every applicant can result in the loss of your company’s ability to contract with Medicare and Medicaid, expose you to civil penalties, and expose your patients to potential danger.

The professionals at iprospectcheck have extensive experience conducting healthcare sanctions checks for providers across the U.S.

Here’s what you should know about Office of Inspector General (OIG) checks.

What is an OIG Background Check?

The U.S. Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) maintains a regularly updated database of individual and group providers who have been excluded from participating in federal healthcare programs called the List of Excluded Individuals and Entities (LEIE).

An OIG screening involves searching the LEIE database to check whether an applicant or employee has been excluded from participating in state and federal healthcare programs.

Hiring or contracting with an individual or entity that has been excluded can result in the loss of the ability to contract with Medicare and Medicaid and expose an organization to substantial monetary penalties.

In many cases, OIG screening is included as a component of a comprehensive healthcare background check that might include numerous searches of a broad variety of state and federal government information sources.

Mandatory OIG Exclusions

OIG exclusions are classified as mandatory or permissive.

An individual or entity might be placed on the mandatory exclusion list for any of the following reasons:

• Medicaid fraud
• Medicare fraud
• Offenses related to the delivery of services or items under Medicare, Medicaid, or state SCHIP programs
• Felony convictions for other types of healthcare fraud
• Felony theft convictions
• Felony financial misconduct convictions
• Felony drug convictions for illegally distributing, prescribing, manufacturing, or dispensing controlled substances

An individual or entity can be mandatorily excluded for five years for the first exclusion.

If they have received two mandatory exclusions, they will be included on the list for 10 years.

Finally, if an individual or entity has received three mandatory exclusions, they will be permanently excluded.

Permissive OIG Exclusions

In most cases, a permissive exclusion will be given for a misdemeanor conviction. The OIG can exercise discretion to issue a permissive exclusion.

The following are some of the reasons why an individual or entity might receive a permissive exclusion:

• Misdemeanor healthcare fraud convictions other than those involving Medicare or Medicaid
• Fraud involving any state or federal program other than healthcare programs
• Misdemeanor convictions for illegally dispensing, prescribing, distributing, or manufacturing controlled substances
• The suspension, revocation, or surrender of the provider’s license for competence, performance, or financial integrity reasons
• Providing substandard or unnecessary medical services
• Submitting fraudulent claims to a federal healthcare program
• Engaging in unlawful kickback schemes
• Defaulting on health student loans or scholarship obligations
• Having an ownership interest in or control of a sanctioned entity

Permissive exclusions are listed on the LEIE database at the OIG’s discretion and typically remain for up to three years.

Other Searches Included in a Healthcare Pre-Employment Background Check

An OIG background screening is typically included in a broader search of a variety of information sources.

In addition to healthcare sanctions checks, other types of searches that are typically performed include the following:

• General Services Administration System of Award Management (SAM) check
• FACIS check
• State sanctions lists
• Employment verification
• Education verification
• Professional license verification
• Domestic terrorist watchlist check
• Sex offender registry search
• Identity verification/Social Security number (SSN) trace
• Criminal background check
• Pre-employment drug test

Performing a comprehensive background screening of any prospective candidate is critical to protect your patients, other employees, and the organization.

Types of Workers Who Should Undergo Screening

Healthcare employers should screen all of the following types of employees and applicants by checking the LEIE and state sanctions lists:

• Registered nurses (RNs)
• Doctors
• Licensed practical nurses (LPNs)
• Physician assistants (PAs)
• Certified nurse aides (CNAs)
• Home health aides (HHAs)
• Physical therapists (PTs)
• Pharmacists
• Pharmacy technicians
• Medical assistants (MAs)
• Emergency medical technicians (EMTs)
• Paramedics
• Any other applicant/employee regardless of position
• Independent contractors
• Vendors
• Volunteers
• Referring practitioners and physicians
• Board members
• Anyone working closely with or for the provider

If you hire anyone who is included in the LEIE, your healthcare company can face the loss of its ability to contract with Medicare and Medicaid and face civil monetary penalties.

State Medicaid Exclusions Lists

To date, 44 states maintain state Medicaid exclusions lists for people in their jurisdictions who have been excluded from participating in Medicaid.

The states must upload this data with the OIG for inclusion in the LEIE.

Since the OIG LEIE is updated monthly, and individual states might have varying schedules for updating their lists and uploading the information to the OIG, there could be a period during which a person is not yet listed on the OIG LEIE.

This makes it important to check all of the following state lists:

• Alabama – List of Suspended Providers
• Alaska – Alaska Excluded Provider List
• Arkansas – Arkansas Department of Human Services (DHS) Excluded Provider List
• California – California Department of Health Care Services (DHCS) Suspended and Ineligible Provider List
• Colorado – Colorado Department of Health Care and Policy Financing (HCPF) Terminated Provider List
• Connecticut – Connecticut Department of Social Services (DSS) Quality Assurance Administrative Actions List
• Delaware – Delaware Sanctioned Providers List
• Florida – Florida Attorney General’s Medicaid Fraud Control Unit Medicaid Sanctioned Providers
• Georgia – Georgia OIG Exclusions List
• Hawaii – Hawaii Department of Human Services Provider Exclusion/Reinstatement List
• Idaho – Idaho Medicaid Exclusions List
• Illinois – Illinois OIG Provider Sanctions
• Indiana – Indiana Family and Social Services Administration (FSSA) Termination of Provider Participation in Medicaid and CHIP
• Iowa – Iowa Medicaid Sanctions List
• Kansas – Kansas Department of Health Care Finance (DHCF) Medicaid Program Integrity Terminated Providers List
• Kentucky – Kentucky Medicaid Provider Termination and Exclusion list
• Louisiana – Louisiana State Adverse Actions List
• Maine – MaineCare Excluded Providers Search
• Maryland – Maryland Medicaid Administration (MMA) Providers and Other Entities Sanctioned List
• Massachusetts – MassHealth List of Suspended or Excluded Providers
• Michigan – Michigan Health and Human Services List of Sanctioned Providers
• Minnesota – Minnesota Excluded Group Providers and Minnesota Excluded Individual Providers
• Mississippi – Mississippi Division of Medicaid Sanctioned Provider List
• Missouri – Missouri Medicaid Program List of Terminations
• Montana – Excluded or Terminated Montana Medicaid Providers
• Nebraska – Nebraska Medicaid Excluded Providers
• Nevada – Nevada Medicaid Sanctions/OIG Exclusions List
• New Hampshire – New Hampshire Medicaid Provider Exclusion and Sanction List
• New Jersey – New Jersey Medicaid Fraud Division Provider Exclusions
• New York – New York State Office of the Medicaid Inspector General (OMIG) Restricted and Excluded Providers
• North Carolina – NC Medicaid Provider Termination and Exclusion list
• North Dakota – ND Medicaid Provider Exclusion List
• Ohio – Ohio Medicaid Provider Exclusion and Suspension List
• Oregon – Oregon Health Plan Sanctioned Providers Search and the OHA State Medicaid Fraud Convictions search
• Pennsylvania – Pennsylvania MediCheck List (Precluded Providers)
• South Carolina – South Carolina Excluded Providers
• Tennessee – TennCare Program Integrity Terminated Provider List
• Texas – Texas OIG Exclusions Search
• Vermont – Vermont Medicaid Portal Excluded Providers List
• Washington – Washington State Healthcare Authority Provider Termination and Exclusion List
• Washington, D.C. – Washington, D.C. Excluded Parties List
• West Virginia – WV Medicaid Provider Exclusions and Terminations
• Wyoming – Wyoming Medicaid Provider Exclusion List

How to Complete an OIG Background Check

1. Do-It-Yourself

Some providers attempt to complete OIG checks by taking a do-it-yourself approach.

They might search the LEIE database to check up to five providers at a time by searching with their Social Security number (SSN) or their Employer Identification Number (EIN).

They can also download the database, but doing so is cumbersome, and the downloadable version is more difficult to verify because it does not include the providers’ SSNs or EINs.

To be thorough, employers should also check the above-listed sanctions lists for any state in which an applicant has previously lived and worked.

Attempting a DIY approach to OIG sanctions checks is time-consuming and laborious. It is also easy to overlook a candidate’s listing on a state sanctions list when they haven’t yet been uploaded into the federal OIG LEIE.

Trying a DIY approach could result in incomplete, inaccurate information and might result in potential penalties.

2. Partnering With a Reliable Provider

The best method for conducting an OIG sanction check is to partner with an experienced and reliable provider like iprospectcheck.

We can streamline the process of completing healthcare sanctions checks and can also conduct searches of other information databases that might be relevant, including comprehensive searches of federal and state government sources.

Additional searches, including General Service Administration Systems and Award Management (SAM) checks and FACIS checks, can reveal information that might not be available through OIG checks alone, including the reason for the individual’s exclusion, whether the sanction is active or has ended, and the board that took disciplinary action.

At iprospectcheck, we also ensure our background checks are comprehensive, accurate, current, and fully comply with the Fair Credit Reporting Act (FCRA).

When you work with us, we can help you navigate all relevant laws that impact employment background checks.

What Laws Govern OIG Checks?

The Social Security Act includes two sections that govern OIG checks as described below.

Section 1128 of the Social Security Act

Section 1128 of the Social Security Act is codified at 42 U.S.C. § 1320a–7.

Under this law, the Secretary of the Department of Health and Human Services is mandated to exclude individuals and entities meeting the list of mandatory exclusions.

DHHS can also use its discretion to issue permissive exclusions based on the previously listed reasons and others.

This statute also defines the exclusion periods for mandatory exclusions of five or 10 years or permanently and also for permissive exclusions of up to three years.

Section 1156 of the Social Security Act

Section 1156 of the Social Security Act is codified at 42 U.S.C. § 1320c–5 and outlines the obligations of healthcare providers and organizations.

Under this law, healthcare organizations must do the following things:

• Only provide services that are medically necessary
• Provide services economically
• Provide services that meet professionally recognized standards of care
• Provide services that are supported by evidence of medical necessity and quality as verified by an auditing body

Penalties Under 42 CFR Part 1003

Under 42 CFR Part 1003, healthcare providers can face penalties and consequences when they hire someone or continue to employ a provider that is included on the LEIE.

Employers can face the following penalties:

• Denial of payment for any services provided in violation of the exclusions list
• Repayment of any amounts received for services provided in violation of the exclusion laws
• Civil monetary penalties of $10,000 for each item or service provided by the excluded individual or entity
• Potential exclusion of the provider that improperly submitted claims of the laws

The penalties can quickly add up. For example, an Ohio company reached a settlement with the OIG this year to pay a $765,000 fine for employing an excluded individual as an intake coordinator.

Turn to iprospectcheck for Fast, Compliant OIG Checks

Healthcare employers that contract with Medicare, Medicaid, and other federal and state healthcare programs must comply with numerous laws and regulations and are prohibited from employing or contracting with excluded individuals and entities.

Failing to perform an OIG check could expose your organization to substantial penalties and consequences while also potentially endangering your patients.

At iprospectcheck, we provide legally compliant, comprehensive, and fast OIG checks for healthcare organizations across the U.S.

To learn more about our comprehensive background check and clinical services and to receive a free quote, call us today: (888) 509-1979

DISCLAIMER: The resources provided here are for educational purposes only and do not constitute legal advice. Consult your counsel if you have legal questions related to your specific practices and compliance with applicable laws.