Category: LEIE

OIG Code Descriptions

How do we understand the Office of Inspector General (“OIG”) and the different codes that they use?  Codes are used for many purposes, and OIG uses many different codes for many different things. When we see codes, we look at it and say something like “what does that mean?”  We want to focus on codes that OIG uses for excluded individuals, or individuals who have been excluded from Medicare, Medicaid, and other state and federal healthcare programs. We hope this makes it so that the next time you see a code by someone’s name, you will understand why they have been excluded. There are 2 categories of exclusions we will talk about. Mandatory and Permissive exclusions.

Mandatory Exclusions: OIG is required by law to exclude the person or entity from all federal healthcare programs. Mandatory Exclusions can be imposed only for these 6 reasons:

  • 1128(a)(1): This code means that the person or entity has been convicted for a program related crime. The exclusion will last for a minimum of 5 years. 
  • 1128(a)(2): This code means that the person or entity has been convicted for something related to patient abuse or neglect. The exclusion will last for a minimum of 5 years.
  • 1128(a)(3): This code means that the person or entity has been convicted for something related to health care fraud. The exclusion will last for a minimum of 5 years. 
  • 1128(a)(4): This code means that the person or entity has been convicted for something related to a controlled substance. The exclusion will last for a minimum of 5 years.
  • 1128(c)(30(G)(i): This code means that the person or entity has been convicted for a 2nd time. The exclusion will last for a minimum of 10 years.
  • 1128(c)(3)(G)(ii): This code means the person or entity has been convicted 3 or more times. The exclusion will be permanent. 

Permissive Exclusions: OIG can choose for themselves to exclude people and entities. These are all the reasons they can choose to exclude an individual or entity: 

  • 1128(b)(1)(A): This code means that the person or entity has had a misdemeanor conviction that is related to health care fraud. The exclusion will have a Baseline period of 3 years (Starting point to check progress of the individual or entity).
  • 1128(b)(1)(B): This code means that the person or entity has been convicted for fraudulent activity in non-health care programs. The exclusion will have a Baseline period of 3 years (Starting point to check progress of the individual or entity).
  • 1128(b)(2) This code means that the person or entity has been convicted for obstruction of an audit or an investigation. The exclusion will have a Baseline period of 3 years (Starting point to check progress of the individual or entity).
  • 1128(b)(3) This code means that the person or entity has had a misdemeanor related to a controlled substance. The exclusion will have a Baseline period of 3 years (Starting point to check progress of the individual or entity).
  • 1128(b)(4) This code means that the person or entity’s license has been revoked, suspended, or surrendered. The exclusion will last however long the state license authority imposes.
  • 1128(b)(5) This code means that the person or entity has been excluded or suspended under a state or federal health care program. The exclusion will last no less than whatever the state or federal program imposes. 
  • 1128(b)(6) This code means that the person or entity claims for excessive charges, unnecessary services or services that fail to meet professionally recognized standards of healthcare, or failure of an HMO (Health Maintenance Organization) to furnish medically necessary services. The exclusion period will last for a minimum of 1 year. 
  • 1128(b)(7) This code means that the person or entity has commited fraud, kickback (bribery), or other activities that are prohibited. The exclusion period has no minimum.
  • 1128(b)(8) This code means that there is an entity that is being controlled by a sanctioned person. The exclusion period minimum is the same length as the exclusion of the individual. 
  • 1128(b)(8)(A) This code means that the entity is being controlled by a family or household member of an individual who has been excluded and the ownership or control of the entity has been transferred or passed to someone else. The exclusion period minimum is the same length as the exclusion of the individual. 
  • 1128(b)(9), (10), and (11) This code means that the person or entity failed to disclose required information, supply the requested information on suppliers and subcontractors, or supply the payment information. The exclusion period has no minimum. 
  • 1128(b)(12) This code means that the person or entity failed to grant immediate access. The exclusion period has no minimum.
  • 1128(b)(13) This code means that the person or entity failed to take corrective action. The exclusion period has no minimum.
  • 1128(b)(14) This code means that a person or entity defaulted on their education loans or scholarship obligations. The exclusion period minimum is until the default or obligation has been resolved. 
  • 1128(b)(15) This code means that a person is controlling a sanctioned entity. The exclusion period minimum is the same length as the exclusion of the entity. 
  • 1128(b)(16) This code means that a person or entity is making false statements or misrepresenting material facts. The exclusion period has no minimum. 
  • 1156 This code means that the person or entity failed to meet statutory obligations of practitioners and providers to provide medical services that meet professionally recognized standards of healthcare. The exclusion period minimum is 1 year. 

We hope that after reading this that OIG codes make more sense to you now. We don’t expect you to memorize them but we do hope that these help you when it comes to choosing an individual or entity for a job or other things related to healthcare. 

References:

  1. https://oig.hhs.gov/exclusions/authorities.asp
  2. https://oig.hhs.gov/exclusions/background.asp

Let’s Talk about Primary Source Data

What is a Primary Source?

A Primary Source is the original source repository or the source that legally issue licenses, discipline, education, training, or examination. A couple of examples of this in our industry are:

California Board of Registered Nursing
Office of Inspector General, U.S. Department of Health and Human Services (OIG)
Pharmacy Technician Certification Board (PTCB)
Centers for Medicare and Medicaid Services (CMS)

What is a Primary Source Data?

Primary Source Data is the license, certification, or disciplinary data directly from the original source. This means the data we collect is directly from the primary source. This data includes exclusion information, opt-out affidavits, license issuance, and disciplinary records. Another caveat to primary source data is we do not change, adjust, or modify the record found at the primary source.

Why is Primary Source Data Important?

Primary source data is important to your company as a way to confirm that your employee can be authorized to work for your facility.

The OIG has the authority to exclude individuals and entities from participation in federal healthcare programs. Any organization or individual who hires excluded parties may be subject to civil monetary penalties (CMP). To avoid these penalties, the LEIE recommends (as a part of the Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs) that you check their database upon hire, and on an ongoing monthly basis.

Primary Source data is not only important to us, it’s important to accrediting bodies (i.e. The Joint Commission, URAC) and exclusion bodies (i.e. OIG, GSA).