Not legal advice. This guide describes common practice and public guidance. Your obligations depend on your state, your provider agreements and your contracts. Talk to a healthcare attorney about your situation, and especially before acting on a confirmed match.
Why screening matters
The HHS Office of Inspector General (OIG) can exclude individuals and entities from federal health care programs. According to the OIG’s Special Advisory Bulletin on the Effect of Exclusion (May 2013), federal health care programs will not pay for items or services furnished, ordered or prescribed by an excluded person, and a provider that employs or contracts with one can face civil monetary penalties and overpayment liability.
States run their own Medicaid exclusion and termination lists as well. A provider terminated by one state’s Medicaid program may not appear on the federal list.
Step 1: Decide who to screen
The OIG bulletin focuses on employees and contractors who furnish, order or prescribe items or services, or who perform administrative and management functions related to them. In practice, many organizations screen:
- Every provider, whether employed, contracted or credentialed for a client
- Staff and contractors, including billing and administrative staff
- Owners, officers and managing employees, where provider agreements ask for it
Step 2: Choose the lists
| List | Screen | Where |
|---|---|---|
| OIG LEIE | Everyone | oig.hhs.gov/exclusions (online search and downloadable file) |
| SAM.gov exclusions | Everyone | sam.gov |
| State Medicaid lists | Each state where the person is licensed, enrolled or practises | Our state-by-state directory |
| Medicare opt-out list | Providers who bill Medicare | data.cms.gov |
The OIG recommends the LEIE as the primary database for exclusion screening because it is maintained by the OIG, updated monthly and has more detail about OIG exclusions than SAM.
Step 3: Screen before hire and every month
Screen before a person starts or is credentialed, then re-screen everyone on a schedule. The OIG updates the LEIE monthly and says monthly screening of employees and contractors best minimizes potential overpayment and penalty liability. Federal rules also require state Medicaid agencies to check the LEIE and federal exclusion list no less frequently than monthly (42 CFR 455.436), and in State Medicaid Director Letter #09-001 CMS directed states to require providers to screen their own employees and contractors.
Step 4: Resolve possible matches
A name match is a question, not a finding. Common names produce false positives, and a real exclusion can hide behind a name change.
- Compare every identifier the list provides: NPI, license number, date of birth, address, provider type.
- For the LEIE, the online search lets you verify a possible match against the individual’s identifying information.
- Check whether the exclusion is current or the person has been reinstated.
- Record who reviewed the match, what they compared and the outcome.
Step 5: Document the results
If you are ever asked to show that screening happened, a record of each run is the evidence. Keep:
- The date of each screening and the list version or “as of” date
- Who was screened against which lists
- Each possible match and how it was resolved, by whom
- A monthly summary you can share with clients or health plans
Step 6: Act on a confirmed match
Follow your compliance policy and get legal advice. Typical steps include removing the person from furnishing, ordering or prescribing items and services billed to federal programs, reviewing claims that may involve them, and deciding with counsel whether repayment or a self-disclosure is needed. The OIG describes its self-disclosure processes on its website. If you screen on behalf of clients, notify the client promptly, as your agreement requires.
Automating it
Doing this by hand every month for every provider and every client is exactly the kind of work that slips. Credentik screens every provider monthly against the OIG LEIE, SAM.gov and the Medicare opt-out list, plus 19 state Medicaid exclusion lists checked automatically, sends possible matches to your team to confirm or clear, keeps the results on each provider’s record and produces a monthly attestation report. See exclusion screening.