What is the difference between a state and federal exclusion?

A federal exclusion is an action taken against an individual or entity by the OIG that excludes them from participating in Medicare and all other Federal health care programs. State exclusions are actions taken by individual states that prevent an individual or entity from receiving state Medicaid funds.

It’s important to note that not all state exclusions are reported to the OIG, so it’s beneficial to screen employees and vendors through all available federal and state exclusions lists.


What are the fines and penalties if you have employed an excluded person or entity?

According to the OIG and regulations, the civil and monetary fines that can be imposed by the OIG is up to $10,000 per item claimed plus up to three times. Further, the claims that were reimbursed may subject you organization to the submission of a False Claim. A repeated or serious infraction can lead to your organization losing its right to bill CMS, and may result in the issuance of a Corporate Integrity Agreement with the OIG or worse being shut down.

Costs of non-compliance

  • 10K for each item/service billed
  • Fines equaling triple that of the amount paid for the services
  • Possible exclusion from federal healthcare programs


Recent examples of OIG exclusion fines

          Fine                                            Excluded person

$92,052.78                                                  residential counselor

$274,721.40                                               medical biller

$34,187.34                                                  x-ray technician

$207,427.34                                               certified nursing assistant

$317,660.89                                               registered nurse

$129,216.80                                               laboratory assistant

$96,259.57                                                  pharmacist



Why conduct exclusion monitoring?

Here are a few reasons to conduct exclusion monitoring.

  1. Healthcare organizations cannot employ an excluded individual or entity if participating in any Federal healthcare program, to do so will result in fines.
  2. Several State Medicaid Agencies have their own state exclusion list.
  3. Several State Medicaid Regulations require monthly exclusion monitoring.
  4. Per the Patient Protection and Affordable Care Act (PPACA) required Center for Medicare and Medicaid Services (CMS) says you should conduct exclusion monitoring. Reference the specific guidance here. Section 6501



What is an exclusion?

An exclusion is defined as administrative action taken by the Office of Inspector General (OIG) and/or State Medicaid Agency to exclude an individual or entity within the healthcare realm based on a criminal conviction(s) and/or a license revocation. The effect of an exclusion is that the person or entity cannot participate in or have federal healthcare dollars reimbursed to their employer, in whole or in part, for their services.