Confirm the match with a Social Security number on OIG’s own search. If it is real, take the person off any work paid for by federal programs that day and hold their claims. Map the dates and roles, value the exposure the way OIG’s Self-Disclosure Protocol does, and decide with a health care attorney whether to refund the overpayment or self-disclose. The 60-day clock for returning overpayments starts when you identify them, so don’t let the file sit.
Estimate the cost now with the excluded employee cost calculator.
Hour 1: confirm the match
Most hits on an exclusion check are a different person with the same name. Acting on a false match can damage a career and expose you to an employment claim, so confirm before anything else.
- Compare the details you already have. The LEIE lists name, date of birth, address, specialty, NPI when there is one, exclusion type and the exclusion date. Compare each with your personnel file. A different middle name or a birth date ten years apart usually settles it.
- Verify on OIG’s site with the SSN. OIG’s online search lets you verify a possible match by entering the person’s Social Security number, or a business’s EIN (OIG search help). This is the confirmation OIG itself provides. Our free tools deliberately never ask for an SSN.
- Check the dates. Note the exclusion date and whether the person has been reinstated. Someone reinstated before your hire date was not excluded while working for you.
- For SAM.gov or a state list, compare identifiers and, if still unsure, contact the agency that published the list. State lists vary in what they include.
Day 1: stop the exposure
Once a match is confirmed, every day the person keeps working adds to the bill. OIG’s 2013 Special Advisory Bulletin says no federal health care program payment may be made for items or services furnished, ordered or prescribed by an excluded person, and that this applies to administrative and management services even when they are not separately billed (OIG bulletin).
- Remove the person from federally reimbursed work. That includes clinical care, but also billing, coding, scheduling, management and IT for a practice that bills federal programs.
- Hold claims they furnished, ordered or prescribed. Don’t submit new claims for their services to Medicare, Medicaid or other federal programs.
- Preserve records. Timesheets, schedules, payroll, claims and the screening history. Don’t edit or delete anything.
- Screen everyone else. OIG’s protocol expects all current employees and contractors to be screened before a disclosure. If one exclusion was missed, check the whole list now.
- Call a health care attorney. Privilege matters in what comes next, and the choice of route is a legal decision.
Screen your whole staff and vendor list in one go with the free bulk exclusion check; it searches OIG, SAM.gov and 16 state Medicaid lists and saves a dated PDF.
Week 1: map the period
The exposure covers the time the person was both excluded and working for you. Build a one-page timeline:
| Date | Where it comes from |
|---|---|
| Exclusion effective date | The LEIE entry (and OIG’s confirmation) |
| Hire or contract start | HR file, contract, staffing agency records |
| Last day of federally reimbursed work | Schedules, timesheets, the date you contained it |
| Reinstatement date, if any | OIG records |
| Each screening you ran | Your screening log and saved records |
Then list what the person did in that window: their roles, which services they furnished or supported, whether any claims carry their name or NPI, and whether they ordered or prescribed anything. OIG asks for the person’s job duties, employment dates, any background checks and your screening process, including where it broke down (Self-Disclosure Protocol).
Week 2: put a number on it
OIG’s protocol uses two methods, depending on the person’s work.
- Services billed under their own name. Total the amounts claimed and paid by each federal program for items and services they furnished, ordered or prescribed during the exclusion.
- Work that isn’t billed separately. Take your total cost of employing or contracting with them during the exclusion (salary, benefits, employer taxes and anything else of value) and multiply by your revenue-based federal health care program payor mix, with a separate calculation for each program.
Quick example. An LPN paid the 2025 national median of $64,400 (BLS) worked 11 months while excluded. With benefits and taxes at 43% of pay (BLS), the cost of employment is $84,418. With half the practice’s revenue from federal programs, single damages are $42,209, and a self-disclosure at the usual 1.5× minimum comes to about $63,313.
Run your own numbers in the excluded employee cost calculator. It also shows the statutory ceiling: up to $25,595 per item or service plus three times the amount claimed (HHS, January 2026).
Five worked examples
The same rule produces very different numbers depending on the role, how long it went on and whether the person billed under their own name. These are hypothetical practices using real pay data and OIG’s published method; the multiplier in a real case can be higher.
| Case | Method | Single damages | Likely self-disclosure | Legal maximum |
|---|---|---|---|---|
| A. Medical records specialist (coder), 5 months | Not billed on their own | $12,188 | $20,000 | Depends on services |
| B. LPN supplied by a staffing agency, 11 months | Not billed on their own | $42,209 | $63,313 | Depends on services |
| C. Physician billing under their own NPI, 7 months | Billed on their own | $84,000 | $126,000 | $28,544,500 |
| D. Medical assistant caught by the next monthly check, 1 month | Not billed on their own | $2,450 | $20,000 | Depends on services |
| E. Nurse reinstated by OIG before your hire date | No exclusion while employed | $0 | $0 | — |
Case A: Medical records specialist (coder), 5 months. Coding work is part of every claim but never billed on its own, so OIG’s cost-of-employment method applies. Payor mix 40%. Pay $51,140 a year for 5 months plus 43% benefits = $30,471; × 40% payor mix = $12,188; × 1.5, raised to the $20,000 minimum = $20,000.
Case B: LPN supplied by a staffing agency, 11 months. The agency missed it, but OIG says liability stays with the provider. Use what you paid the agency for this nurse if that is higher than pay plus benefits. Pay $64,400 a year for 11 months plus 43% benefits = $84,418; × 50% payor mix = $42,209; × 1.5 = $63,313.
Case C: Physician billing under their own NPI, 7 months. Damages start from what Medicare and Medicaid paid for the physician’s own services: $84,000 paid on $130,000 claimed for 1,100 services. 1.5 × $84,000 = $126,000. The statutory ceiling is 1,100 × $25,595 plus 3 × $130,000 = $28,544,500, which shows why nobody wants OIG to find this first.
Case D: Medical assistant caught by the next monthly check, 1 month. Single damages are small, so OIG’s $20,000 minimum settlement sets the price. This is what monthly screening limits you to. Pay $45,690 a year for 1 month plus 43% benefits = $5,445; × 45% payor mix = $2,450; × 1.5, raised to the $20,000 minimum = $20,000.
Case E: Nurse reinstated by OIG before your hire date. Reinstated people are removed from the current list. If reinstatement came before their start date, there was no excluded period and nothing to repay.
Why the first month matters
The estimate grows in a straight line with time, but OIG’s $20,000 minimum means short cases all cost about the same. The chart shows the likely settlement for three common roles at a 45% federal payor mix, by how long the person worked before anyone noticed.
| Months undetected | Medical assistant | LPN/LVN | Registered nurse |
|---|---|---|---|
| 1 | $20,000 | $20,000 | $20,000 |
| 3 | $20,000 | $20,000 | $23,540 |
| 6 | $22,051 | $31,081 | $47,080 |
| 12 | $44,102 | $62,162 | $94,160 |
| 24 | $88,205 | $124,324 | $188,320 |
Screening monthly keeps a missed exclusion near the left of this chart. Screening once a year can leave it anywhere up to twelve months; screening only at hire can leave it at the far right.
Choose the route
There are a few ways to resolve it. Which one fits depends on the facts, the amounts and whether there are signs of anything beyond a screening failure. This table shows how they differ; the choice belongs with your attorney.
| Route | What it resolves | What to know |
|---|---|---|
| Refund the overpayment to the payer (Medicare contractor, state Medicaid) | Returns the money paid for the excluded person’s items or services | Meets the duty to return overpayments, but does not by itself resolve OIG’s civil monetary penalty authority |
| OIG Self-Disclosure Protocol | Resolves OIG’s penalty liability through a settlement | Usually at least 1.5× single damages and a $20,000 minimum; CMS suspends the 60-day reporting obligation once OIG acknowledges a timely submission |
| State Medicaid self-disclosure | Medicaid overpayments under state rules | Each state has its own process; New York requires a full self-disclosure when an employee is found on an exclusion list |
Sources: OIG Self-Disclosure Protocol, NY OMIG.
The 60-day clock
The law requires Medicare and Medicaid overpayments to be reported and returned by the later of 60 days after they are identified or the date a related cost report is due. For Medicare Parts A and B, a CMS rule effective January 1, 2025 changed what “identified” means: you have identified an overpayment when you knowingly receive or retain it, the same standard as the False Claims Act, covering actual knowledge, reckless disregard and deliberate ignorance (Foley summary of the final rule).
The same rule lets a timely, good-faith investigation pause the 60-day deadline for up to 180 days while you work out the related overpayments. That is time to investigate, not time to wait.
State Medicaid
Medicaid is run by each state, and each has its own exclusion list, recovery unit and disclosure process. New York is a useful example: OMIG’s self-disclosure program is the required way to report Medicaid overpayments found through self-review, gives an employee found on an exclusion list as an example that needs a full self-disclosure, uses a six-year lookback, and offers a mixed-payer calculation for excluded people paid from several sources (NY OMIG).
Check your own state agency’s rules, and remember that managed care plans often have contract terms of their own. Our directory of state Medicaid exclusion lists links to every state’s program.
The person involved
OIG’s rules are about payment, not about what the person may do with their life. OIG’s bulletin allows a provider to employ an excluded person only where no federal health care program pays for that work, directly or indirectly. For a practice that bills federal programs, that leaves very little.
- Keep the conversation factual and private. Share what the official record shows and what it means for their role.
- Follow your employment policies and get advice before ending anyone’s employment.
- Point them to OIG: only OIG can explain their exclusion, and reinstatement requires an application to OIG once the exclusion period ends.
What to document
- The screening result that flagged the person, with the date and the list version.
- Your confirmation on OIG’s site (date, who checked, the result).
- The timeline: exclusion date, start date, containment date, any reinstatement.
- Duties performed and which services they touched.
- The damages calculation and the assumptions behind it (payor mix by program, pay and benefits).
- Containment actions: the date the person stopped federally reimbursed work and when claims were held.
- The screening of everyone else, with dated results.
- Advice received, the route chosen and every submission and payment.
- The change you made so it can’t recur.
Make sure it doesn’t happen again
OIG updates its list every month and recommends monthly screening of employees and contractors (OIG bulletin). That is the single biggest fix, because it limits any future gap to about a month.
- Screen at hire and every month, by name as well as NPI. Most people on the LEIE have no NPI listed.
- Cover contractors and agencies. Ask staffing agencies and billing vendors for their screening records; liability stays with you.
- Check former names. Ask for previous names at hire and screen them too.
- Keep a dated record of every check. It is your evidence of what you knew and when.
You can do this free each month with the bulk exclusion check, or have it run automatically. Put the routine in writing with the free screening policy generator.
- Your staff, contractors and vendors saved once (up to 250 names)
- Re-screened every month against the OIG list, SAM.gov and the Medicaid lists of 16 states
- An email the day a run finds a new possible match, with the record details
- A dated PDF screening record emailed every month, ready for audits and credentialing
- Unlimited on-demand checks of your saved list, any time
Save your list once. We re-check it every month after OIG’s update and email you the dated PDF record. Cancel any time.
Start Practice ProHow it worksWhat your attorney will ask
Having these answers ready shortens the first call and the bill.
- How did you find it: routine monthly screening, a payer, a tip or an audit?
- Is the match confirmed on OIG’s site with the SSN, and on what date?
- What is the exclusion date and type, and is there a reinstatement or waiver?
- When did the person start and stop federally reimbursed work for you?
- What did they do: own claims under their NPI, ordering or prescribing, or support work?
- Which federal programs did you bill in that period, and what was your payor mix for each?
- What do your screening records show, month by month?
- Were they hired directly or through an agency or vendor, and what does that contract say about screening?
- Have you screened everyone else, and with what result?
- Is there any sign of something beyond a screening failure, such as false statements on an application?
Sample incident note
A short, factual note written the same day helps everyone later. Keep opinions out of it. An example, with invented details:
Who is excluded today (live)
These charts come from OIG’s current monthly exclusion file, the same data our free checks use, and update every month. They show why people from every corner of health care, not just doctors, turn up on the list.
Eight costly mistakes
- Firing on a name match before confirming with the SSN.
- Letting the person keep working “until we know more” after confirmation.
- Only looking at billed services when the person was support staff; OIG counts the cost of employment.
- Using one blended payor mix when OIG wants each federal program calculated separately.
- Assuming the staffing agency is liable, not you.
- Waiting for the full figure before starting the 60-day process.
- Forgetting state Medicaid and managed care contracts.
- Fixing this case but not the process, so it happens again.
Questions
Do we have to tell anyone if we find an excluded employee?
If federal programs paid for items or services the person furnished, those payments are overpayments, and the law requires overpayments to be reported and returned within 60 days of being identified. How you report (a refund to the payer, OIG’s Self-Disclosure Protocol or a state Medicaid self-disclosure) is a decision to make with a health care attorney.
Can we keep the person on in a role federal programs don’t pay for?
OIG’s 2013 bulletin allows employment only where no federal health care program pays for the person’s services, directly or indirectly. For a practice that bills Medicare or Medicaid, that is a very narrow set of roles. Get legal advice before relying on it.
What if they were reinstated before we hired them?
Reinstated people are removed from the current LEIE. Check the reinstatement date against your hire date in OIG’s reinstatement records. If they were reinstated before they started, there was no exclusion while they worked for you.
Does self-disclosure stop the 60-day deadline?
According to OIG’s protocol, CMS agreed to suspend the obligation to report overpayments once OIG acknowledges receipt of a timely Self-Disclosure Protocol submission, and to suspend the return obligation until a settlement or withdrawal.
How much will a self-disclosure cost?
OIG generally applies at least 1.5 times single damages and, since 2021, requires a minimum settlement of $20,000 for matters that are not kickback-related. Our excluded employee cost calculator estimates it from pay, months and payor mix.
The excluded person came from a staffing agency. Is that our problem?
Yes. OIG’s bulletin says the provider is liable for overpayments for items or services furnished by an excluded person, regardless of who did the screening. Ask the agency for its screening records and review your contract.
How far back do we need to look?
To the later of the exclusion date and the person’s start date. The civil monetary penalties law allows actions up to six years after a claim was presented, and New York’s OMIG uses a six-year lookback for Medicaid self-disclosures.
Sources
- HHS OIG, Health Care Fraud Self-Disclosure Protocol (issued April 17, 2013, amended November 8, 2021) — what a disclosure involving an excluded person must contain, how damages are valued, the 1.5× multiplier, the $20,000 minimum and the suspension of the 60-day obligation
- HHS OIG, Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs (May 8, 2013) — the payment ban and its scope, contractor liability and when an excluded person can be employed
- 42 U.S.C. § 1320a-7a(a), civil monetary penalties (Cornell LII) — the penalty, assessment and six-year limit
- HHS, Annual Civil Monetary Penalties Inflation Adjustment, Federal Register, January 28, 2026 (employing or contracting with an excluded individual: $25,595) — the $25,595 inflation-adjusted maximum per item or service
- Foley & Lardner, CMS final regulations on the 60-day overpayment refund rule (effective January 1, 2025) — the 60-day rule, the “knowingly” standard and the 180-day investigation period from January 1, 2025
- HHS OIG, Exclusions database help — verifying a match with a Social Security number or EIN on OIG’s search
- NY OMIG, Self-Disclosure Frequently Asked Questions — an example state Medicaid self-disclosure program, its 60-day rule and six-year lookback
- U.S. Bureau of Labor Statistics, Occupational Outlook Handbook: healthcare occupations, 2025 median pay — LPN pay in the worked example
- U.S. Bureau of Labor Statistics, compensation costs for private industry workers, June 2026 — benefits as a share of pay
This guide is general information about federal and state rules as of October 26, 2026. It is not legal advice. Talk to a health care attorney about your situation.