QUESTIONS CONCERNING
EXCLUSIONS
What is
the LEIE?
The Office of Inspector General's
(OIG) List of Excluded Individuals/Entities
(LEIE) database provides information to
the health care industry, patients and the
public regarding individuals and entities
currently excluded from participation in
Medicare, Medicaid and all Federal health
care programs. Individuals and entities
who have been reinstated are removed from
the LEIE.
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What authority does the
OIG have to take these actions?
The OIG imposes exclusions under the authority
of sections 1128 and 1156 of the Social
Security Act.
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What is the effect of
an exclusion?
No payment will be made by any Federal
health care program for any items or services
furnished, ordered, or prescribed by an
excluded individual or entity. Federal health
care programs include 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). For exclusions
implemented prior to August 4, 1997, the
exclusion covers the following Federal health
care programs: Medicare (Title XVIII), Medicaid
(Title XIX), Maternal and Child Health Services
Block Grant (Title V), Block Grants to States
for Social Services (Title XX) and State
Children's Health Insurance (Title XXI)
programs.
No program payment will be made for anything
that an excluded person furnishes, orders,
or prescribes. This payment prohibition
applies to the excluded person, anyone who
employs or contracts with the excluded person,
any hospital or other provider where the
excluded person provides services, and anyone
else. The exclusion applies regardless of
who submits the claims and applies to all
administrative and management services furnished
by the excluded person.
There is a limited exception to exclusions
for the provision of certain emergency items
or services not provided in a hospital emergency
room. See regulations at 42 CFR 1001.1901(c)
Additional information is available in
the Special
Advisory Bulletin on the Effect of an Exclusion.
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What are the different
types of exclusions?
The different types of exclusions can be
found here.
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What types of actions
are included in the LEIE?
The LEIE contains only exclusion actions
taken by the OIG. There are many bases for
an exclusion, including a conviction related
to the Medicare or Medicaid program, a conviction
related to patient abuse, or an action taken
by a State licensing authority. The LEIE
only reports exclusion actions taken by
the OIG as a result of those other actions.
The LEIE is not a clearinghouse for reporting
actions taken by other agencies.
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When were exclusion actions
first implemented?
The OIG has been implementing exclusions
since about 1981, but the Department first
began imposing them in 1977.
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Does an exclusion effect
a person's right to receive benefits under
the Medicare, Medicaid and all Federal health
care programs?
No. An exclusion affects only the ability
to claim payment from these programs for
items or services rendered; it does not
affect the ability to receive benefits under
the programs.
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How does an individual
or entity get removed from the LEIE?
Reinstatement of excluded entities and individuals is not automatic. Those wishing to again participate in the Medicare, Medicaid and all Federal health care programs must apply for reinstatement and receive authorized notice from the OIG that reinstatement has been granted. Obtaining a provider number from a Medicare contractor, a State agency or a Federal health care program does not reinstate eligibility to participate in those programs. There are no provisions for early or retroactive reinstatement.
Upon written request to the OIG at the below listed address, the OIG will provide Statement and Authorization forms which must be completed, notarized and returned. The information contained in these forms will be evaluated and a written notification will be sent indicating the final decision of the OIG pertaining to the reinstatement request. Generally, this process requires up to 120 days to complete, but can take longer if circumstances warrant.
Excluded parties may write to the OIG within 120 days of the expiration of the minimum period of exclusion to request reinstatement. Premature requests will not be considered.
If reinstatement is denied, the excluded party is eligible to reapply after one year.
To apply for reinstatement, send a request to:
HHS, OIG, OI
Exclusions Staff
7175 Security Boulevard, Suite 210
Baltimore, MD 21244
Additional information in regulations can be found at 42 CFR 1001.3001-3005.
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QUESTIONS CONCERNING THE DATABASE
What is the data format
for the LEIE?
The LEIE is available in two formats:
The Online Searchable Database enables
users to enter the name of an individual
or business and determine whether an exclusion
is currently in effect. If a match is made
on an individual, the database can verify
with an individuals Social Security Number
(SSN) that the match is unique. Employer
Identification Numbers (EIN) (also known
as Tax Identification Numbers (TIN)) are
being included for recently excluded entities.
The Downloadable Database File enables users
to download the LEIE file to a personal
computer and establish an independent database
or combine the file with existing data.
Monthly exclusion data files are posted
on the web site on a monthly basis, as are
reinstatement data files if you wish to
add to your database. A continuously updated
file is also available if you do not wish
to rely on the supplements.
Note: the Downloadable Database File does
not contain SSNs or EINs. Therefore, verification
of specific individuals or businesses through
the use of the SSN or EIN must be done with
the Online Searchable Database.
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How do I use the downloadable
LEIE with supplements?
The List of Excluded Individuals/Entities
(LEIE) is a database file (DBF) that has
been zipped into a self-extracting file.
In Windows, you may extract the file by
typing the file name at the Run command,
or by clicking on the file name in Explorer.
The DBF is compatible with database programs
such as Access and spreadsheet programs
such as Excel. Please refer to your user's
manual for instructions on using DBF files
with your software program.
Main LEIE: After downloading and extracting
the main LEIE, open it in whichever program
you opt to use.
Monthly Exclusion Supplements: Add or append
each subsequent monthly exclusion supplement
to the LEIE.
Monthly Reinstatement Supplements: The
monthly reinstatement supplement should
NOT be added or appended to the LEIE. Use
it as a guide for manually inserting the
reinstatement date in the LEIE by taking
the following steps:
1. Identify each individual and entity
listed in the monthly reinstatement supplement
2. Locate the matching individuals and entities
in the LEIE
3. Manually insert the reinstatement dates
in the LEIE
By adding or appending the exclusion supplements
and manually inserting the reinstatement
dates obtained from the monthly reinstatement
supplements, the LEIE datafile will remain
current.
Record Layout for file:
LASTNAME 20
FIRSTNAME 15
MIDNAME 15
BUSNAME 30
GENERAL 20
SPECIALTY 20
UPIN 6
DOB 8
ADDRESS 30
CITY 20
STATE 2
ZIP 5
SANCTYPE 9
SANCDATE 8
REINDATE 8
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What information is
included in the LEIE?
The online searchable database contains
all individuals and entities currently excluded.
Individuals and entities who have been reinstated
are removed from the LEIE.
The downloadable database file contains
all individuals and entities that were excluded
as of the date the file was produced. The
exclusion supplements contain all individuals
and entities excluded during each month
subsequent to the original LEIE. The reinstatement
supplements contain all individuals and
entities reinstated during each month subsequent
to the original LEIE.
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When are the online
and downloadable sites updated with new
information?
The sites are generally updated in the
middle of the month. The updates include
all actions taken during the prior month.
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What is the difference
between the LEIE and the GSA web site?
The GSA web site contains debarment actions
taken by various Federal agencies, including
exclusion actions taken by the OIG. The
LEIE contains just the exclusion actions
taken by the OIG. You may access the GSA
web site at: http://epls.arnet.gov
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What are the NPDB and
the HIPDB?
The National Practitioner Data Bank (NPDB)
was created as a result of the Health Care
Quality Improvement Act of 1986 and became
operational in September 1990. It contains
information on various actions taken against
physicians and dentists.
The HIPDB (Healthcare Integrity and Protection
Data Bank) was created as a result of the
Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and became operational
in March 2000. It contains information on
various actions taken against health care
practitioners, providers and suppliers.
These databanks are not available to the
public. For more information on the databanks,
go to http://www.npdb-hipdb.com
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Why is there a field
to input a SSN at the online searchable
site, but the SSNs aren't available at the
downloadable site?
The Privacy Act prohibits disclosing Social
Security Numbers (SSN), so they can not
be included in the downloadable file. However,
the online searchable site uses the SSN
input by the user as one of the matching
criteria. It does not supply SSNs to users.
If you are a user of the downloadable site
and have a possible match on an individual
and want to verify with a SSN, you should
use the online searchable SSN feature to
verify the identity.
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How do I obtain information
on a date of birth or UPIN (and SSN in the
online searchable database) if it isn't
in the LEIE?
If the date of birth, UPIN or SSN is not
in the LEIE, it is not available from the
OIG.
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What is a UPIN?
The Unique Physician Identification Number
(UPIN) was established by the Health Care
Financing Administration (HCFA) as a unique
identifier in lieu of the SSN. Transamerica
Occidental in Los Angeles is the clearinghouse
for the UPIN Registry. UPINs are assigned
to physicians as well as certain non-physician
practitioners and medical group practices.
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How can I obtain a
copy of an individual or entity's exclusion
notice?
Submit a written request with a printout
from the LEIE identifying the individual
or entity. Requests without the printout
will be returned. Generally, the only documentation
available is the exclusion notice which
informs the subject of the exclusion, its
effect and the subject's appeal rights.
It does not contain specific details regarding
the basis for the exclusion. If the subject
has also been reinstated, the notice informing
the subject of that action is available.
Mail the request to the address in the
Contact information for the Exclusion Program
listed here.
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How can I report fraud
or abuse relating to the Medicare and Medicaid
programs?
You can I report fraud or abuse relating
to the Medicare and Medicaid programs by
using the contact information found on the
OIG Hotline
page.
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What is the telephone
number, mailing address, etc.?
Contact information for the Exclusion Program
can be found here.
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