The CMS Do Not Hire List: 5 Best Practices for Your Facility

The Centers for Medicare and Medicaid Services (CMS) is a vital component of the U.S. healthcare system, providing coverage for over 100 million people. Public databases known as CMS do not hire lists (or exclusion lists) provide facility leaders with a record of individuals who have violated federal or state laws in the patient care setting, and therefore should not be allowed to participate in any aspect of CMS funding. Past violations could include Medicare and Medicaid fraud, illegal distribution of medications, patient abuse, and neglect.

Healthcare facilities are responsible for checking these lists to ensure that federal funding doesn’t go to those who have threatened the integrity of the healthcare system in the past. This often involves enacting an exclusion screening policy to flag individuals who should either not be hired, or (if currently employed) should be investigated for potential termination.

Below, we’ll dive into the details of this approach, explain why it’s important for your facility, and provide five best practices for ensuring the protection of your patients.

What Is Exclusion Screening?

In order to deliver quality care, facilities must be able to tell if a potential employee has ever committed a crime in the medical field. This method of screening, also known as exclusion monitoring, is the process of confirming that an employee or contractor is not prohibited (i.e., “excluded”) from participating in federally funded programs.

This is often done by accessing and searching key public databases. The primary federal exclusion list that facilities are required to check regularly is formally titled the List of Excluded Individuals/Entities (LEIE). It’s often referred to as “the CMS do not hire list” because any facility or agency that participates in federal healthcare funding is prohibited from employing or contracting with an individual on the list.

How Does Someone Get on the OIG Exclusion List?

Practitioners (such as doctors, nurses, and administrators) who have been convicted of previous healthcare-related crimes are put on this public list for easy lookup. Excluded individuals and entities may have been placed on the list due to a range of violations, including criminal offenses and misdemeanor convictions.

Criminal offenses result in mandatory exclusion (the most severe sanction), and may involve:

• Medicare or Medicaid fraud.
• Other healthcare-related fraud, theft, or financial crimes.
• Patient neglect or abuse.
• Unlawful distribution or dispensing of controlled substances.

Misdemeanor convictions result in permissive exclusions (a less severe sanction), and may involve:

• Fraud in a federally funded, non-healthcare program.
• Misdemeanor convictions related to unlawful involvement with controlled substances.
• Suspension of a license to provide healthcare.
• Provision of substandard services.
• Engagement in a kickback arrangement.
• Defaulting on a healthcare education loan.

Additional CMS Do Not Hire Lists

Many states maintain their own Medicaid exclusion lists. Healthcare providers who have violated state laws but not necessarily federal laws are reported on these databases. For example, the New York Office of the Medicaid Inspector General (OMIG) exclusion list contains names of individuals who have violated New York laws but might not be on the main federal lists.

An additional CMS exclusion list that facilities may have to monitor is the CMS Preclusion List. Not all facilities have access to this list. It’s available for Part D plans and Medicare Advantage (MA) plans. The database is different from the broader CMS do not hire lists because it specifically identifies individuals who should be prevented from receiving payment for certain Part D and MA services.

When Should Facilities Conduct Screenings?

Prior to (and periodically after) the hiring of any new employee, companies are legally required to confirm that each staff member is allowed to provide medical treatment. Some payers even require facilities to conduct monthly screenings, since this is how often the OIG updates the LEIE.

In addition to a normal background check, facilities will enter the individual’s name into federal and state exclusion databases to verify that the employee is cleared to work. Services such as Streamline Verify, ProviderTrust, and Compliatric can be used to streamline the process, cross-reference multiple databases, and provide ongoing monitoring.

Why Is Exclusion Monitoring Important?

By doing their due diligence and preventing repeat offenders from harming their patients, each facility maintains responsibility for ensuring safe and ethical treatment. Any company caught hiring someone on the LEIE could be subject to hefty fines of up to $10,000 for each item or service furnished by the excluded individual, an assessment of up to three times the amount claimed, and possible exclusion from federal healthcare programs.

5 Best Practices for Performing Exclusion Checks

By conducting exclusion screening, healthcare facilities can ensure the best possible care for their patients and protect themselves from liability. Here are five best practices that can help you effectively incorporate this process into your security protocols.

1. Familiarize Yourself With Your Resources

Healthcare compliance officers can access federal and state databases to check the status of every new and existing employee. To ensure legal compliance, healthcare businesses should do a thorough screening of federal exclusion lists and any applicable state lists.

Many search engines claim to perform an in-depth analysis of employee qualifications, making it complicated to know exactly where to begin. To help you get started, we’ve listed three main resources that companies reference when clearing employees.

2. Explore Name Variations and Other Identifiers

Federal and state lists include the names of the individuals as they were listed at the time of the offense. Including previous names, nicknames, and other patient identifiers (birthdate, Social Security numbers, addresses, etc.) in your search can ensure accurate results.

3. Screen Upon Hiring, and Monthly Afterward

Facilities need to perform exclusion screening for every newly hired employee, contractor, and vendor. CMS recommends performing monthly exclusion checks to verify current staff’s compliance. Routine screening is important, as poor oversight could lead to detrimental patient harm and substantial fines for your facility.

4. Consult Legal Counsel

If a current or prospective employee comes up on a state Medicaid exclusion list, SAM exclusion list, or OIG exclusion list, you should speak to a lawyer. It’s important to follow the necessary steps for reporting. The employee may need to be terminated promptly, a decision and process that should be reviewed by counsel. Documenting that you handled the situation in a timely manner is necessary, so make sure to save evidence (screenshots, time stamps, emails, and documents) for potential legal review.

5. Hire a Chief Compliance Officer to Help

Periodically reviewing employee compliance can take a considerable amount of time, but hospital management is often swamped with many other important tasks. Consider appointing a member of staff to manage screening procedures, such as OIG exclusion monitoring, auditing, and reporting.

A chief compliance manager can efficiently process and organize the data necessary to verify that your team members are allowed to work. They can keep documents centralized and secure, and are aware of laws pertaining to employment. Prioritizing safety and accountability within your facility’s leadership structure may minimize your legal exposure and help you to deliver safe, quality care to your patients.

Discover More Ways to Ensure High Quality Care

Regularly engaging with CMS do not hire lists can save your facility from headaches, fines, and compromised patient care. Looking for more support? Our healthcare facility guides and resources deliver valuable information that can help you provide ethical, high-quality care.

Legal Disclaimer: This article contains general legal information, but it is not intended to constitute professional legal advice for any particular situation and should not be relied on as professional legal advice. Any references to the law may not be current, as laws regularly change through updates in legislation, regulation, and case law at the federal and state level. Nothing in this article should be interpreted as creating an attorney-client relationship. If you have legal questions, you should seek the advice of an attorney licensed to practice in your jurisdiction.