A Checklist for Effective Exclusion Monitoring Processes

Not all exclusion monitoring practices are created equal.

Truly effective exclusion monitoring calls for a nuanced understanding of the Health and Human Services Office of Inspector General (HHS-OIG) guidelines and best practices—plus, an ability to adapt to changes as they occur.

With over 15 years of experience, the ProviderTrust team has built and enhanced countless exclusion monitoring programs for organizations of all sizes. A solid exclusion monitoring program will protect patient safety and prevent fraud, waste, and abuse from creeping into your organization.

At ProviderTrust, we evaluate the impact of an exclusion monitoring program using three pillars: population, primary sources, and frequency. Start by asking these questions to determine where you currently stand, and then map out where you’d like to end up and the steps you’ll need to get there.

1

Which population(s) do you monitor for exclusions?

2

Which primary sources do you monitor regularly?

3

How frequently do you monitor those primary sources?

How do your processes measure up?

Our first recommendation: If you haven’t already adopted an automated solution, now is the time. Manual exclusion monitoring is less common than it used to be, but legacy processes and budget constraints keep some organizations from making the change. The peace of mind will be worth it.

If you already have an automated exclusion monitoring solution, the next step is to evaluate who you’re monitoring, what your sources are, and how frequently you’re checking those sources. If your current program has a strong foundation, it may be time to level up into gold-standard practices.

The difference between a status-quo program and a gold-standard program is all in the details. For example, you cannot work with any excluded individual or entity—even if your organization only practices in Montana and a provider is excluded in Tennessee. But are you monitoring every disparate state exclusion list? For many organizations, the answer is no, and blind spots like that leave significant gaps in coverage.

POPULATION

✔ Employees

✔ Providers (whether employed or contracted, par or non-par)

✔ Referring and ordering physicians

✔ Some vendor entities

✔ Employees

✔ Providers (whether employed or contracted, par or non-par)

✔ Referring and ordering physicians

✔ All vendor entities

✔ All vendor owners

PRIMARY SOURCES

✔ HHS-OIG List of Excluded Individuals and Entities (LEIE)

✔ GSA SAM.gov

✔ State Medicaid Lists (for limited states)

✔ HHS-OIG List of Excluded Individuals and Entities (LEIE)

✔ Medicare Opt Out

✔ SSN Death Master File

✔ GSA SAM.gov

✔ CMS Preclusion List

✔ NPPES NPI Registry

✔ All State Medicaid Lists

✔ OFAC SDN and Non-SDN List

FREQUENCY

✔ Monthly for employees

✔ Monthly for providers

✔ One initial check for ordering and referring physicians

✔ One initial check for vendors

✔ None for vendor owners

✔ Automated ongoing monitoring for all populations