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 90 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
Office of Investigations
Health Care Administrative Sanctions
Room N2-01-26
7500 Security Boulevard
Baltimore, MD 21244-1850

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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