Exclusions

Your revalidation roster is not your screening roster

The CMS revalidation file tells you when an enrollment is due. It contains no exclusion column, no license status, and no debarment flag. A roster that is clean on revalidation can still be paying an excluded biller, and a provider can be clear on the OIG list and still be barred from federal contracts.

Three files answer three different questions. Most compliance programs check one of them, document it badly, and find out at the settlement.

The part people miss is the supplement

OIG replaces the full downloadable database each month and also publishes a monthly supplement containing only that month's additions and reinstatements. If your process is "we downloaded the file in January and we check new hires against it," the file is stale and the reinstatements are invisible. A reinstatement matters as much as an exclusion: the record stays on the list forever, and only the reinstatement date tells you the person is clear.

Two mechanical details decide whether your file survives an audit. The downloadable database omits SSNs, so identity verification has to happen through the online search, which accepts up to five names at a time. And OIG asks you to keep documentation of the search and any follow-up, not just the result. A screenshot with no date is not documentation.

What the rules actually say

• OIG's 2013 Special Advisory Bulletin recommends screening before employment or contracting and periodically afterward, and notes that monthly screening best minimizes overpayment and civil monetary penalty exposure. It is guidance, not a universal statutory mandate for every private practice.
• 42 CFR 455.436 requires state Medicaid agencies to check the LEIE and SAM at least monthly, and many states push a similar cadence down to enrolled providers through the provider agreement.
• Medicare Advantage and Part D contracts commonly require plans and their contracted providers to screen before hire and every month after.
• Penalties sit in 42 CFR 1003.210: civil monetary penalties per item or service, plus an assessment of up to three times the amount claimed. The exposure compounds per claim, not per employee.

This page is a summary with sources, not legal advice. Your state Medicaid agreement and your payer contracts decide your cadence.

We are not going to out-database anyone

Screening is a mature category. Streamline Verify, Exclusion Screening, ProviderTrust, Verisys, and symplr already sell database coverage, match resolution, and audit reports. A one-person product claiming fifty-state coverage would be lying by omission: state lists change format, some states publish no separate list at all, and match resolution is human work.

So we are not selling screening. We are adding one column to the roster you already reconcile for enrollment: exclusion status, refreshed from the monthly supplement, with the date and the source on every row. If you need full screening with a resolution team, buy one of the vendors above. If the problem is that your enrollment roster and your screening roster have quietly drifted apart, that is the gap we can close.

What the column would do

• Carry LEIE and SAM status on the same rows as the CMS due date, so one file answers both questions.
• Diff the monthly supplement against your roster and report only additions, reinstatements, and identifier changes.
• Produce a dated screening log per month: who was screened, against which file, on what date, with the reviewer recorded.

It is in build, with design partners, and it will not ship as a fifty-state claim. See the status of every registry.

Questions we get on calls