Exclusion monitoring in healthcare is the process of routinely checking federal and state databases — such as the Office of Inspector General’s (OIG) and the System for Award Management (SAM) — to identify individuals or organizations barred from participating in federally funded healthcare programs. This monitoring protects healthcare organizations from hiring, contracting, or reimbursing excluded providers, which can lead to severe financial penalties, repayment demands, and reputational harm. It’s important to note that a “potential match” does not automatically mean the provider is excluded. Further investigation and verification must be completed before action is taken.

MedTrainer automatically checks OIG, SAM, and all other state and federal exclusionary databases on an NCQA-approved schedule. Once the provider is added to MedTrainer’s platform and the exclusion databases are selected, the checks run monthly (or weekly for SAM) until the employee is terminated. Notifications are automatically sent when a new exclusion is discovered so you can quickly and accurately identify excluded parties. MedTrainer’s healthcare exclusions monitoring solution checks the OIG-LEIE monthly and SAM database weekly, with date and exclusion list automatically tracked in the platform to ensure you’re compliant and survey ready.

Over 40 federal and state exclusionary databases are included in the automated checks completed by MedTrainer. There are seven states that report directly to the OIG, rather than maintaining their own list. These states include: New Mexico, Oklahoma, Rhode Island, South Dakota, Utah, Virginia, and Wisconsin. All other state databases are included in MedTrainer’s exclusion monitoring software. When you set up each provider within MedTrainer, you’ll select the exclusion databases to be checked for that provider. There is no additional cost for multiple databases, which makes MedTrainer a very cost-effective solution for organizations who operate in multiple states or who provide telehealth services.

MedTrainer’s exclusion monitoring software checks the OIG List of Excluded Individuals and Entities monthly and SAM databases weekly. It’s vital these checks are completed on a recurring basis because if a healthcare organization employs or pays an excluded provider, even unintentionally, it can result in civil monetary penalties, repayment of all claims, and potential exclusion from federal programs themselves. Because exclusions can happen at any time, it’s very important healthcare organizations catch exclusions before payments or claims are made.

Using MedTrainer’s exclusion monitoring software, you’ll receive an email notification when a scheduled check is completed and a provider’s exclusion status has changed. You will be able to verify the identity of the individual or entity by comparing demographic information like date of birth, NPI, and full legal name. Every step of the review should be documented, including any additional action. If the exclusion is confirmed, the provider must be terminated from any role involving federally funded healthcare programs until the individual is reinstated by the OIG. Automated alerts give healthcare organizations confidence that affiliated individuals and entities are eligible to participate in federal funding programs and be reimbursed for care.

The National Committee for Quality Assurance (NCQA) sets the gold standard for healthcare quality and credentialing practices. Even healthcare organizations who are not NCQA accredited strive to stay aligned with the standards. The automated checks completed through MedTrainer’s exclusion monitoring software are completed every 30 days as required by NCQA. Performing exclusion checks in alignment with these standards helps prevent high-risk scenarios such as billing for excluded providers, which can lead to regulatory penalties, loss of contracts, or repayment demands. Maintaining this schedule also keeps provider data accurate and audit ready.

• Exclusion monitoring software is an incredible time saver for busy healthcare credentialing teams. It is very time consuming to manually visit the federal and state exclusion website, checking every staff member, and then tracking that the check has been completed. This process should be completed at least monthly, so the time savings of an automated system are substantial. Exclusion monitoring solutions like MedTrainer utilize automation technology to check each database for you with the results automatically tracked and available in real-time reports. In addition to the time savings of an automated system, there is also greater accuracy. Exclusion monitoring software helps organizations maintain a higher standard of integrity and safeguard their operations from risks associated with excluded individuals or entities. 

MedTrainer’s exclusion monitoring software makes it possible for credentialing teams to set it and forget it. They can trust best-in-class automation software to check databases for them, track the results, and deliver email notifications if anything requires investigation. This frees up valuable time for credentialing teams and streamlines the entire credentialing process to keep staff compliant.

Every healthcare exclusion check is logged automatically with the provider’s information, date, and database information so you can demonstrate compliance. This data is added to the provider’s profile in MedTrainer, and is also available in customizable reports that can be saved and scheduled to email on a recurring basis to both internal and external email addresses. This report is especially useful when a surveyor is on site and asks to see the dates of the most recent exclusion checks. It is also a great way to spot check monthly to ensure the checks are running as expected and any status changes are being reported via email notifications.

MedTrainer’s exclusion monitoring software completes checks automatically every 30 days and sends automated email notifications when an individual or entity’s status changes. This means healthcare organizations can take action to ensure an excluded professional is not providing patient care or billing. Violations can result in penalties of up to $100,000, so there is great incentive for healthcare organizations to use exclusion monitoring solutions like MedTrainer to avoid these expenses. Reporting capabilities within MedTrainer’s exclusion monitoring software also allow you to generate audit-ready reports when you need them. With these features, MedTrainer helps prevent financial penalties and non-compliance issues by keeping you audit-ready.

Automated exclusion monitoring solutions are most valuable for healthcare organizations with large or regulated workforces, including hospitals and health systems, community health centers (FQHCs), multi-site clinics, ambulatory surgery centers (ASCs), post-acute providers, and specialty groups such as labs and behavioral health. The larger an organization, the more employees who need to be checked monthly for exclusions. Any organizations who receive federal funding or are Medicare certified must also strictly adhere to the requirements, which mean not employing or billing for excluded individuals or entities.

If each exclusion check takes five minutes to complete, then it could take 50 minutes for an organization with five employees and 40 hours — and entire work week! — for an organization with 500 employees. Plus, this needs to be completed every single month. It’s absolutely a cost-saving measure for large organizations, but it is also valuable for small organizations who don’t have a dedicated staff member to complete these checks manually. Often the person completing these checks is also the receptionist or scheduler or even the HR professional, so they have plenty of other important tasks to be completed.