Delegated Entity Exclusion, Sanction & Debarment Checks. OIG/GSA database screening

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Edwina Webb
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1 Delegated Entity Exclusion, Sanction & Debarment Checks OIG/GSA database screening 2016

2 Contents Sanction/Exclusion/Debarment Checks... 2 Office of Inspector General (OIG)... 2 Searching for Exclusions in OIG:... 2 Searching multiple names in OIG:... 4 OIG Secondary Checks:... 5 LEIE Downloadable Databases:... 6 Searching for Exclusions in SAM:... 8 Searching multiple names in SAM:... 9 Searching SAM using the monthly downloadable database:...11 Secondary Checks in SAM:...12 Secondary Check Documentation:...14 State Exclusion Checks

3 This guide is designed to be a quick reference guide for completing OIG and GSA exclusion checks, and to provide some examples and recommendations that have developed from issues and areas of confusion that our partners have experienced in implementing effective oversight of this requirement. This is not intended to replace the guidance provided on the official sites and should not be considered the final source of guidance for your oversight process. Sanction/Exclusion/Debarment Checks FDR regulatory guidance requires pre-hire, and monthly thereafter, checks of both the HHS-OIG (Health and Human Services - Office of Inspector General) and GSA (General Services Administration) Federal programs exclusion lists for all employees* who are involved in the administration or delivery of UHC MA or Part D benefits or services to ensure that none of these persons or entities are excluded or become excluded from participation in federal programs. If you serve UHC Community Plans, you are also required to review state exclusion lists at the time of hire and monthly thereafter, as referenced in the regulatory appendix of your vendor contract(s) or if modified by state requirements since contract execution. Throughout this document, the term employee includes contractors, consultants, temporary workers, volunteers, the CEO, Executive, Management, governing bodies and sub delegates/entities etc....who work in any capacity with Federal health care programs. This includes Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan). Office of Inspector General (OIG) The OIG s List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. Searching for Exclusions in OIG: 1. Go to You will be able to search For an Individual; For a Single Entity; For Multiple Individuals; For Multiple Entities. Below are some examples for Single and Multiple Individuals. 2

4 2. Enter individual s first/last name of individual 3. If No Match, the following screen will be displayed: 3

5 Searching multiple names in OIG: 1. Select Search for Multiple Individuals to search up to 5 at a time. 2. Enter all Individuals First and Last Names 3. If No Match, the following screen will be displayed: Additional Recommendations: We have identified some instances where an individual was not initially identified due to a recent name change &/or hyphenated last name. It is recommended that you check hyphenated names under all possible options to ensure they are not excluded. If a person has a name change, we do recommend that you check the exclusion lists under both names for a period to ensure they are clear. For example: Jane Osborn-Wesley should be checked for the following options; Jane Doe Smith Jane Doe-Smith Jane Doe Jane Smith 4

6 OIG Secondary Checks: Same or similar names may appear on the list. For example: John Smith inquiry shows the following results: You would then match the individual by additional information such as Middle name; SSN/EIN under verify option. Example, if you click on verify option for John D Smith, you will then receive additional information for validation such as DOB; Address, and the option to enter your employee s SSN or EIN to verify full data. If the SSN does not match you will see the following: 5

LEIE Downloadable Databases: If you have a large group of individuals to search, consider downloading the entire list via the LEIE Downloadable Database to your computer and using a spreadsheet or

7 LEIE Downloadable Databases: If you have a large group of individuals to search, consider downloading the entire list via the LEIE Downloadable Database to your computer and using a spreadsheet or database program to perform searches. Note: The Downloadable Database does not contain SSNs or EINs. Therefore, verification of specific individuals or businesses through the use of the SSN or EIN must be done via the Online Searchable Database. You can also check your entire employee database against the monthly LEIE database. Once you have done the initial check, you can continue to do monthly checks by confirming that your employee has not been ADDED TO the exclusion list since the previous monthly check by ensuring your employee(s) does not appear on the updated monthly LEIE database. This can be found here: 6

8 This page also contains links to the current monthly supplement files, profile updates and corrections, current record layout information as well as general information about the files: LEIE Database reflects the entire database, as of the date indicated, for all OIG exclusions. Current Monthly Supplements database updates include all new names added to the exclusion list since the previous update. If you have done your initial check with the entire database, and confirmed all secondary checks to ensure no matches, you can check your list against the Monthly Supplement Exclusion list each month going forward instead of checking against the full database, or performing individual name searches. 7

9 It is up to you to determine which method works best for your organization. If you review your employees against the monthly updated lists, you must retain both the employee roster and the monthly downloaded list for documentation. Both versions of the List of Excluded Individuals/Entities are generally updated by the middle of the month. The updates include all actions taken during the prior month. Recommendation: Please make sure that your date formats are the same when doing data base comparisons between your employee list and the updated exclusion lists. We have had instances where individuals were not properly identified due to the different formatting of the date of birth fields on the different excel documents. General Service Administration (GSA) General Service Administration (GSA) administers Excluded Parties List System (EPLS) and System for Award Management (SAM), both of which contain debarment actions taken by various Federal agencies, including exclusion actions taken by the OIG. The List of Excluded Individuals/Entities contains only the exclusion actions taken by the OIG. You may access the SAM at The SAM is the Official U.S. Government system that consolidated the capabilities of CCR/FedReg, ORCA, and EPLS. Searching for Exclusions in SAM: 1. Go to Click Search Records tab 2. For an individual, search by typing name in the QUICK SEARCH box: 8

If No Match, the following screen will be displayed: Searching multiple names in

10 If no exclusion record is found for the individual, the individual does not have an active exclusion submitted in SAM by a federal agency. If No Match, the following screen will be displayed: Searching multiple names in SAM: 1. From the Home Page click on the Search Records tab 2. Click on the ADVANCED SEARCH EXCLUSION 9

11 4. Click on the Multiple Name Search radio button 5. Select Individual in the drop down. 6. Enter First Name and Last Name - Click Search If No Match, the following screen will be displayed: 10

provides details for accessing publicly available data from SAM.

12 Searching SAM using the monthly downloadable database: Access the SAM website using the link above, and select DATA ACCESS from the menu bar (see below) The Data Access page provides details for accessing publicly available data from SAM. Each data package includes the description for more information. Below is an example of what you can access from this page: 11

Secondary Checks in SAM: If an exclusion record is found, it will display in a box marked Exclusion in purple; check the status in the top-right corner of the box.

13 Secondary Checks in SAM: If an exclusion record is found, it will display in a box marked Exclusion in purple; check the status in the top-right corner of the box. If the status indicates Active, there is an active exclusion for that entity. Here s an example. Note that the search result with the green box marked Entity is an Entity Management search result. The result with the purple box marked Exclusion is a Performance Information (Exclusion) search result: To view additional details, expand each result by clicking the + in the upper-right corner of the result. If the individual is listed on with Exclusion Active, click on the View Details button. Click View Details to view an entire record. In View Details the individual address can be compared to determine No Match. 12

14 Positive Match: In the event it is discovered that an employee is noted on the exclusion lists the entity is required to immediately remove the employee from any work related directly or indirectly on all Federal health care programs and notify all impacted Carriers. Record Retention: You must retain the appropriate level of documentation to confirm that you have checked all required individuals prior to hire, and each month thereafter, and that you have retained the documentation to indicate when the database check occurred, the names /lists checked, and any screenshots to verify the secondary checks needed, as applicable. Sample Documentation: The following is a sample log for when the database check occurred: Delgated Entity: Year: OIG AND GSA EXCLUSION LIST TRACKER ( ( Date exclusion list database was updated: 12/10/2014 1/8/2015 2/9/2015 FDR EMPLOYEE INFORMATION JANUARY FEBRUARY MARCH EMPLOYEE NAME HIRE DATE Date of Birth TERM DATE OIG DATE GSA DATE RESULT OIG DATE GSA DATE RESULT OIG DATE GSA DATE RESULT Employee Name 1 06/01/94 xx/xx/xx 01/05/15 01/05/15 NO RESULT 02/02/15 02/02/15 NO RESULT Employee Name 2 06/01/94 xx/xx/xx 01/05/15 01/05/15 Finding* 2nd check: No Match 02/02/15 02/02/15 NO RESULT Employee Name 3 01/01/82 xx/xx/xx 01/05/15 01/05/15 NO RESULT 02/02/15 02/02/15 NO RESULT Employee Name 4 01/01/82 xx/xx/xx 01/05/15 01/05/15 NO RESULT 02/02/15 02/02/15 NO RESULT Employee Name 5 08/13/03 xx/xx/xx 01/05/15 01/05/15 NO RESULT 02/02/15 02/02/15 NO RESULT 13

15 Secondary Check Documentation: The first time you check your employee against the OIG or GSA database, and have a partial hit that requires secondary check (as in Employee Name 2 example above), you will need to retain the screen prints that show No Match, which will clearly identify how you validated that your employee did not match the record. OIG Screen Shot Sample: GSA Screen Shot Sample: All supporting documentation should be retained for the 10 years per CMS regulatory guidance. 14

16 State Exclusion Checks State-Based Exclusions: Pursuant to 42 CFR (b), a State has the authority to exclude an individual or entity from Medicaid for any reason or period authorized by State law. Section 1128(b)(5) of the Social Security Act (the Act) specifies that providers who are suspended or excluded from participation or otherwise sanctioned for reasons bearing on professional competence, professional performance, or financial integrity (hereafter referred to as final actions) by State Medicaid agencies are subject to a permissive exclusion by the federal OIG. Upon receiving a referral from a State, OIG staff review the referral to determine whether to pursue an exclusion case based on the federal criteria for exclusion. Many States maintain state-based sanction/exclusion databases that are in addition to, but do not replace, the OIG federal exclusion databases. A Provider may not participate in the network of a specific state if the provider is listed on that State s exclusion list, even if the provider is not listed on a federal exclusion list. State Exclusion list resource: Verify Comply is a vendor that offers several exclusion list search options. Their website provides a list of exclusion lists checked by their portal for both Federal and State. 15

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