The OIG exclusion list, formally called the List of Excluded Individuals/Entities (LEIE), is the federal database of people and organizations barred from billing Medicare, Medicaid, and every other federally funded healthcare program. It is maintained by the Department of Health and Human Services Office of Inspector General.1Office of Inspector General. About OIG Landing on it ends most healthcare careers for the duration of the exclusion, exposes any employer who misses it to five-figure penalties per claim, and requires an affirmative application to get off even after the minimum period runs.
What Puts Someone on the List
Exclusions come in two flavors. Some are mandatory, meaning the OIG has no choice once the underlying conviction exists. Others are permissive, meaning the OIG decides case by case.
Mandatory Exclusions
Section 1128(a) of the Social Security Act requires exclusion, with a five-year minimum, for anyone convicted in four categories:2Office of Inspector General. Background Information and Exclusion Authorities
- Program-related crimes tied to delivering items or services under Medicare, Medicaid, or another federal healthcare program.
- Patient abuse or neglect connected to healthcare delivery.
- Felony fraud, theft, or embezzlement related to healthcare, even outside a federal program.
- Felony unlawful manufacture, distribution, or dispensing of a controlled substance.
Five years is the floor. A prior conviction that would itself qualify for mandatory exclusion pushes the minimum to ten years. Two or more prior qualifying convictions produce a permanent exclusion with no reinstatement available.3eCFR. 42 CFR 1001.102 – Length of Exclusion
Permissive Exclusions
Section 1128(b) gives the OIG discretion to exclude for conduct that falls short of the mandatory triggers. The common ones are misdemeanor healthcare fraud convictions, state license revocation or suspension, providing unnecessary or substandard care, and defaulting on federally backed health education loans or scholarship obligations.4Office of the Law Revision Counsel. 42 USC 1320a-7
The baseline permissive exclusion for a misdemeanor healthcare fraud conviction is three years.2Office of Inspector General. Background Information and Exclusion Authorities License-based exclusions run at least as long as whatever the state licensing authority imposed. Loan-default exclusions last until the debt is resolved. The OIG applies aggravating and mitigating factors to set the actual length, and the mitigating list is short: three or fewer misdemeanors with under $5,000 in program losses, a diminished-responsibility condition documented in court records, or cooperation that produced other convictions, exclusions, investigations, or civil monetary penalties.3eCFR. 42 CFR 1001.102 – Length of Exclusion Nothing outside those three categories will bring the period down.
What Exclusion Actually Blocks
Federal program payments cannot cover the salary, benefits, or overhead of an excluded individual in any capacity, including administrative and back-office work. The OIG has specifically flagged billing agents, accountants, claims processors, and utilization reviewers as roles that trigger the payment prohibition when filled by an excluded person.5Office of Inspector General. The Effect of Exclusion From Participation in Federal Health Care Programs
There is one narrow exception. A provider can employ an excluded person using exclusively private funds for work that relates solely to non-federal patients.5Office of Inspector General. The Effect of Exclusion From Participation in Federal Health Care Programs Segregating funding streams that precisely is difficult, and most employers will not attempt it.
What It Costs an Employer Who Misses It
If a healthcare provider bills federal programs for items or services connected to an excluded individual, the statutory civil monetary penalty is up to $20,000 per item or service claimed, adjusted for inflation to $25,595 per violation. On top of that, the government can seek an assessment of up to three times the amount improperly claimed.6Office of the Law Revision Counsel. 42 USC 1320a-7a – Civil Monetary Penalties The penalty applies whether or not the employer knew about the exclusion. Not knowing is not a defense.
That is why screening matters. The OIG updates the LEIE by the 10th of every month and expects state Medicaid agencies to check it monthly and at enrollment. Other healthcare entities are advised to check regularly for new hires and current employees to avoid CMP liability.7Office of Inspector General. LEIE Quick Tips and Instructions
Challenging an Exclusion
Every exclusion notice can be appealed, but the window is tight. The individual or entity has 60 days from the notice to request a hearing before an HHS Administrative Law Judge.8eCFR. 42 CFR 1001.2007 – Appeal of Exclusions Miss it and the right to a hearing is gone.
An adverse ALJ decision can be appealed to the HHS Departmental Appeals Board, and federal court review is available after the DAB issues a final decision.9Office of Inspector General. Frequently Asked Questions – Exclusions For mandatory exclusions the practical scope is limited: the OIG only has to prove the conviction occurred and falls into one of the four categories. Hardship and rehabilitation arguments carry no weight at that stage. Permissive exclusions leave more room to contest how the OIG exercised its discretion and weighed the factors.
Waivers
Waivers of mandatory exclusions exist but are narrow. The Secretary of HHS may waive one only when the excluded individual is the sole community physician or the sole source of essential specialized services and enforcement would harm program beneficiaries. Only the administrator of a federal healthcare program can request the waiver. The excluded person cannot apply.10Office of Inspector General. Waivers Convictions for patient abuse or neglect are statutorily ineligible, and the Secretary’s decision is not subject to judicial review.4Office of the Law Revision Counsel. 42 USC 1320a-7
Getting Off the List
Exclusion does not lift on its own. Once the minimum period ends, the individual or entity has to apply for reinstatement in writing. The request goes to the OIG by email or mail and must include the full name (with any names used during the exclusion), date of birth, phone number, email address, and mailing address.11Office of Inspector General. About Reinstatements
The OIG then evaluates whether the applicant still poses a risk to federal programs and beneficiaries. Current professional licensure, rehabilitative steps taken during the exclusion, and a clean record since the original conviction all help. Review commonly runs 90 to 120 days and can take longer in complicated cases.
Two things surprise people. Billing federal programs remains prohibited until reinstatement is formally granted, even if the minimum exclusion period ended months earlier. And federal reinstatement does not clear a person from any state Medicaid exclusion list; that has to be handled separately through the state’s own process.
Other Lists to Know About
The LEIE is not the only federal exclusion database. The System for Award Management (SAM) covers debarments and exclusions across all federal programs, not just healthcare, and the two are not automatically synchronized. Someone can be on one and not the other. Many states also keep their own Medicaid exclusion lists, and an individual can appear on a state list without being on the LEIE. For a healthcare organization to actually know whether a hire is clear, checking the LEIE alone is not enough.