In 1977, in the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Public Law 95-142 (now codified at section 1128 of the Act), Congress first mandated the exclusion of physicians and other practitioners convicted of program-related crimes from participation in Medicare and Medicaid. This was followed in 1981 with the enactment of the Civil Monetary Penalties Law (CMPL), Public Law 97-35 (codified at section 1128A of the Act), to further address health care fraud and abuse. The CMPL authorizes the Department and OIG to impose CMPs, assessments, and program exclusions against any person that submits false or fraudulent or certain other types of improper claims for Medicare or Medicaid payment. Claims submitted by an excluded person for items or services furnished during the person’s exclusion violate the CMPL.

To enhance OIG’s ability to protect the Medicare and Medicaid programs and beneficiaries, the Medicare and Medicaid Patient and Program Protection Act of 1987, Public Law 100-93, expanded and revised OIG’s administrative sanction authorities by, among other things, establishing certain additional mandatory and discretionary exclusions for various types of misconduct. The enactment of the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, in 1996 and the Balanced Budget Act (BBA) of 1997, Public Law 105-33, further expanded OIG’s sanction authorities. These statutes extended the application and scope of the current CMP and exclusion authorities beyond programs funded by the Department to all “Federal health care programs.” BBA also authorized a new CMP authority to be imposed against health care providers or entities that employ or enter into contracts with an excluded person to provide items or services for which payment may be made under a Federal health care program.

Since the publication of the 1999 Bulletin, various statutory amendments have strengthened and expanded OIG’s authority to exclude individuals and entities from the Federal health care programs. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care Education Reconciliation Act of 2010 (ACA), expanded OIG’s exclusion waiver authority. The ACA also modified and expanded OIG’s permissive exclusion authorities and amended the CMPL by adding a new provision that subjects an excluded person to liability if the person orders or prescribes an item or a service while excluded and knows or should know that a claim for the item or service may be made to a Federal health care program. For more information, please go to http://oig.hhs.gov/exclusions/background.asp

Providers and contracting entities have an affirmative responsibility to routinely verify the exclusion status of individuals and entities and maintain a record.

Violations and Civil Monetary Penalty (CMP) amounts of the OIG LEIE fall under the False Claims Act (FCA). Details of CMP assessment include:

• Fines for each item or service furnished by the excluded individual or entity.
• An assessment of up to three times the amount claimed (the amount paid to the health care organization by the government program going back as many as 6 years).
• Government Funded Program exclusion

CMPs are codified and adjusted for inflation annually. The latest adjustments can be referenced at 45 CFR § 102.3 as well as
45 CFR § 1003.210.

The Venops exclusion screening process is straightforward:

1. An encrypted spreadsheet uploaded from your Venops dashboard provides an “exclusion screening template” with the individuals and entities you want to screen.
2. Your list is cross checked against a direct-source database of every applicable exclusion & sanction authority.
3. Professional in-house clearance investigations are included with Venops. Thorough screening records are created and archived for instant access on your dashboard.
4. Our software instantly identifies all possible exclusion matches by name and source.
5. Venops access includes monthly Autopilot screening. The Venops system remembers every name previously screened and re-checks each of them automatically against the new updated exclusion & sanction database. This provides you with an updated, current exclusion report every month without fail.

This is a statement we hear often enough to address it in our FAQ. Yes – exclusion screening still applies. This is why:

The OIG mandate not only includes exclusion screening to identify and avoid the employment or affiliation with excluded parties, but also the requirement to maintain screening records. Routine screening records are a powerful mitigating factor to prove due diligence for audit purposes.

There are multiple exclusion and sanction lists tracked by Venops. While the federal OIG LEIE and GSA SAM are the most recognized, the majority of states have additional provider sanction lists that are also included.

• OIG LEIE
• GSA SAM
• All existing state Medicare sanctioned provider lists.
• OFAC SDN
• Tricare
• DEA criminal cases against doctors
• DOJ EOIR list of disciplined providers
• FDA debarment list
• Medicare opt-out affidavits
• Medicare waivers list
• Additional state lists are added as they are created by each state

Click the Memberships tab above to review additional details.

Venops is well known in the healthcare industry as a reliable steward of the sensitive information critical for effective compliance services, and trust is our most cherished principle. Venops uses industry exceeding encryption with SOC 2 elements to protect the data shared for service fulfillment. Additional protocols are in place to further reduce risk.