Health care providers and entities routinely check the Office of Inspector General’s (“OIG”) List of Excluded Individuals and Entities (“LEIE”) prior to employing or entering into a contract with an individual to determine the exclusion status of the potential employee or contractor. However, it is important that health care providers and entities participating in Medicare also check the General Services Administration’s (“GSA”) System for Award Management (“SAM”) for debarred employees or contractors.
The Medicare regulations require that providers and suppliers participating in the Medicare program not employ or contract with individuals or entities that are: 1) excluded by the OIG from participating in any federal health program; or 2) debarred by the GSA from any other Executive Branch procurement or non-procurement programs or activities. The LEIE list only includes exclusion actions taken by OIG. SAM includes the OIG’s exclusions, but also includes debarment actions taken by other federal agencies.
The penalty for employing or contracting with an excluded or debarred individual or entity is to preclude payment by Medicare for items or services furnished or ordered by the excluded party. For example, no payment may be made to a hospital for services furnished by an excluded nurse to Medicare beneficiaries, even if the nurse’s services are not separately billed. The prohibition on Medicare payment for services furnished by excluded individuals goes beyond direct patient care services and includes such services as inputting prescription information for pharmacy billing, patient transportation services, and administrative and management services.
In addition to recouping Medicare payment for services provided by an excluded individual or entity, civil money penalties may be imposed against health care providers or entities that employ or enter into contracts with excluded individuals or entities to provide services or items covered by the Medicare program.
When performing pre-employment and periodic annual checks on employee and contractor exclusion status, health care providers and entities should check both the LEIE and the SAM lists to ensure that they are compliant with the Medicare participation rules.
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