Study guide
13.3 The OIG Exclusion List & Sanctioned-Provider Screening
AHIP Medicare Certification Exam
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1 Introduction
1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide
2 Chapter 2: Medicare Program Fundamentals
2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)
3 Chapter 3: Medicare Enrollment Periods
3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)
4 Chapter 4: Medigap & Coordination of Coverage
4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact
5 Chapter 5: Medicare Advantage Plan Types
5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)
6 Chapter 6: Special Needs Plans & MA Plan Design
6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality
7 Chapter 7: Part D Structure & the 2026 Redesign
7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)
8 Chapter 8: Part D Costs, Assistance & Appeals
8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals
9 Chapter 9: CMS Marketing Rules & Scope of Appointment
9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events
10 Chapter 10: Enrollment & Disclosure Requirements
10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules
11 Chapter 11: Marketing Conduct & Oversight
11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight
12 Chapter 12: Understanding Fraud, Waste & Abuse
12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute
13 Chapter 13: Compliance Laws & Screening
13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening
14 Chapter 14: Reporting, Compliance Programs & Consequences
14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans
13.3 The OIG Exclusion List & Sanctioned-Provider Screening
Key Takeaways Explain This Topic AI
OIG's List of Excluded Individuals/Entities (LEIE) is a monthly-updated, publicly searchable database barring people and organizations from all federal health care programs under Social Security Act Section 1128.
Mandatory exclusions (fraud convictions, patient abuse, controlled-substance felonies) carry a minimum 5-year bar with no OIG discretion; permissive exclusions are case-by-case and vary in duration.
Exclusion functions as a payment prohibition that extends beyond clinical services to administrative and management roles tied to federal health programs.
CMS requires plan sponsors, agencies, and agents (as First Tier, Downstream, and Related Entities) to screen against both the LEIE and the SAM.gov excluded parties list before engagement and monthly thereafter.
Reinstatement after an exclusion period ends is not automatic — the excluded party must apply and OIG must approve the application.
Last updated: July 2026
- The OIG Exclusion List & Sanctioned-Provider Screening
- Why This Topic Matters
Every one of the fraud statutes covered so far — the False Claims Act, the Anti-Kickback Statute, and the Stark Law (Chapter 12 and Section 13.1) — describes conduct that is prohibited. This section covers the enforcement mechanism that follows: how the federal government bars people and organizations from Medicare and Medicaid entirely, and how CMS requires plan sponsors, agencies, and agents like you to actively check for those bars before doing business with anyone. AHIP tests this as a concrete, procedural compliance duty — not just legal theory — because screening lapses are one of the most common real-world compliance failures found during CMS program audits of Medicare Advantage and Part D sponsors.
Core Terms and Rules
The Office of Inspector General (OIG) , part of the U.S. Department of Health and Human Services (HHS), has statutory authority under Section 1128 of the Social Security Act to exclude individuals and entities from participating in all federal health care programs — not just Medicare, but Medicaid, TRICARE, and others. OIG maintains this bar list as the List of Excluded Individuals/Entities (LEIE) , a free, publicly searchable database at exclusions.oig.hhs.gov, updated monthly and currently containing tens of thousands of entries.
A separate but related list is maintained by the General Services Administration (GSA) : the System for Award Management (SAM.gov) excluded parties list, which covers exclusions across the broader federal contracting and grant-making system (not just health care). CMS requires Medicare Advantage and Part D sponsors — and, by extension, the agencies and agents who sell on their behalf — to check both the LEIE and SAM.gov before hiring or contracting with anyone, and then monthly thereafter for the duration of the relationship.
Mandatory vs. Permissive Exclusions
OIG exclusions fall into two categories, and the AHIP exam tests the distinction between the two:
Type Basis Minimum Duration Examples
Mandatory Required by law — no OIG discretion At least 5 years Felony conviction for Medicare/Medicaid fraud; patient abuse or neglect; felony conviction for other health-care-related financial misconduct; felony conviction for unlawful manufacture, distribution, or dispensing of controlled substances
Permissive Discretionary — OIG evaluates case-by-case Varies (often shorter, but can be longer) Misdemeanor health-care fraud convictions; license revocation or suspension by a state board; kickback-related violations; default on health education loan or scholarship obligations
Note that mandatory exclusions require at least a 5-year bar — this is a specific number the exam may test directly, since it is the one hard-coded duration in an otherwise discretionary system.
What Exclusion Actually Means
Exclusion is not a mild administrative flag — it functions as a payment prohibition . No federal health care program may pay, directly or indirectly, for any item or service furnished, ordered, or prescribed by an excluded individual or entity. This prohibition is broader than most agents initially assume: it extends to administrative and management services , meaning an excluded person cannot even work in a non-clinical, back-office role (like billing or scheduling) for an organization that participates in federal health care programs, if that role touches program-related functions.
Exclusion is not automatically lifted when the exclusion period ends. The excluded individual or entity must affirmatively apply for reinstatement , and OIG reviews the application before restoring eligibility — being off the calendar does not mean back on the list is automatic removal.
Screening Obligations for Agents and Agencies
CMS requires Medicare Advantage and Part D sponsors to screen all employees and First Tier, Downstream, and Related Entities (FDRs) — a category that includes independent agents, agencies, and marketing organizations — against both exclusion databases:
Before hire, appointment, or contracting.
Monthly thereafter, for as long as the relationship continues.
This screening duty is one of the required elements of a compliance program (covered in full in Chapter 14), and failure to screen is a recurring finding in CMS program audits.
Penalties for Non-Compliance
If an organization employs or contracts with an excluded individual and submits claims for items or services that person furnished, OIG can impose a civil monetary penalty of roughly $25,595 per item or service claimed (2026 inflation-adjusted figure), in addition to requiring repayment of amounts already paid. An organization with a pattern of failing to screen can itself face compliance sanctions from CMS, including corrective action plans or, in severe cases, contract-level sanctions.
Exam Scenario
An agency's compliance officer runs the monthly LEIE check and discovers that a downline agent — actively selling Medicare Advantage plans under the agency's contract — was added to the exclusion list three weeks ago following a state license revocation. The agency must act immediately: the agent cannot continue selling or performing any function connected to federal health care programs, the agency must terminate the relationship (or reassign the agent to fully unrelated, non-program work, if such a role genuinely exists), and the incident must be reported through the agency's and carrier's compliance channels. Continuing to allow enrollments to flow through that agent after discovering the exclusion would itself expose the agency to civil penalties.
Key Takeaways
OIG maintains the LEIE, a monthly-updated public database barring individuals and entities from all federal health care programs under Social Security Act §1128 authority.
Mandatory exclusions (fraud convictions, patient abuse, controlled-substance felonies) carry a minimum 5-year bar with no OIG discretion; permissive exclusions are discretionary and vary in length.
Exclusion is a broad payment prohibition — it bars payment for clinical services and extends to administrative/management roles connected to federal programs.
CMS requires screening all employees and FDRs (including agents and agencies) against both the LEIE and SAM.gov before engagement and monthly thereafter.
Reinstatement after an exclusion period ends is not automatic — the excluded party must apply and OIG must approve it.