Medicare exclusion screening: a practical guide
How to screen for Medicare exclusions: OIG LEIE, who to check, monthly screening guidance, potential matches, documentation, and CMS preclusion.
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What is Medicare exclusion screening?
It is checking people and entities against OIG’s List of Excluded Individuals/Entities (LEIE) to identify exclusions affecting Medicare payment. OIG exclusions prohibit federal program payment for items or services furnished, ordered, or prescribed by excluded parties. This can include indirectly paid administrative work. Providers that know or should know of an exclusion can face civil monetary penalties as well as overpayment exposure.
Read OIG’s payment and liability guidanceWhich organizations and people are affected?
Hospitals, physician practices, nursing facilities, home health agencies, pharmacies, laboratories, suppliers, and health plans should assess their Medicare-funded work. OIG recommends reviewing each job category and contract for direct or indirect federal payment, then screening the people performing that work. Include relevant employees, volunteers, contractors, subcontractor staff, and ordering or prescribing clinicians. Billing and staffing arrangements deserve attention too.
OIG’s role and contractor analysisIs monthly Medicare exclusion screening required?
OIG does not impose a universal statutory or regulatory LEIE screening schedule on providers. It recommends checks before hiring or contracting and periodically afterward; monthly checks best limit exposure because the LEIE updates monthly. Validate any additional program, payer, state, or contract duties separately.
OIG’s frequency guidanceAs an operational practice, assign an owner and recurring deadline, check that the new source release is available, and track overdue runs. A scheduled job alone does not show that screening finished or that someone resolved its alerts.
Are LEIE, SAM, and CMS preclusion the same?
No. The LEIE lists current OIG exclusions. SAM includes OIG exclusions and debarment actions from other federal agencies. Neither a license nor a credentialing check establishes LEIE status. Use the LEIE for OIG exclusions and identify other checks that apply to your work.
OIG’s explanation of LEIE and SAMCMS’s Preclusion List is a separate Medicare Advantage and Part D payment control. CMS requires MA plans to deny payment for listed providers’ items or services and Part D sponsors to reject claims for drugs prescribed by listed individuals. Coordinate applicable preclusion checks with your plan; a clear LEIE result does not establish preclusion status.
CMS’s Preclusion List guidanceIf you also participate in Medicaid, assess state requirements separately using the controlling agency’s instructions.
Explore Exclia’s state requirement guidesHow do you run a Medicare exclusion check?
Prepare a roster of the people and entities in scope. Assign a reviewer and record the sources and schedule your organization has selected.
Search the official LEIE online for a few names, or use the downloadable database for a larger roster. Refresh downloaded data monthly, including reinstatements if using supplements.
Search current and former names and relevant name variations. Follow OIG’s punctuation and hyphenated-name instructions.
Review possible matches, record the outcome, and escalate unresolved cases before closing the run.
For an automated workflow, check roster completeness, source freshness, failed jobs, and reviewer follow-up. When a contractor screens for you, request evidence of its checks; outsourcing does not remove the provider’s potential liability.
OIG’s guidance on outsourced screeningDoes a matching name mean someone is excluded?
No. OIG says a matching name is insufficient. Verify a potential match in its online database using the individual’s SSN or entity’s EIN; downloaded files omit these identifiers. If identifying information is unavailable, contact OIG’s Exclusions Branch. Keep the case unresolved while investigating rather than assuming the person is clear.
OIG’s identity verification instructionsFor a confirmed match, promptly involve your compliance or legal team to address affected work and payments. If the party already worked for you, OIG directs readers to its Self-Disclosure Protocol. Reinstatement is not automatic when an exclusion period ends: OIG must grant it in writing.
OIG’s positive-match and reinstatement FAQsWhat screening documentation should you keep?
OIG instructs users to retain initial name searches and follow-up verification searches. Use the online tool’s Print Search Results function to preserve its results.
OIG’s documentation instructionsOur suggested run record includes the roster, date, source release, search terms, results, match evidence, reviewer, disposition, escalation, and completion date. Set retention and access rules with your compliance team. Use approved channels for sensitive identifiers; do not put SSNs or EINs into Exclia’s public checker or worksheet.
Get the free checklist and editable worksheetOfficial sources and related Exclia resources
- OIG: Effect of Exclusion — Special Advisory Bulletin (May 8, 2013)
- OIG: LEIE Quick Tips and Instructions
- OIG: Exclusions FAQs
- CMS: Medicare Advantage and Part D Preclusion List