This article is part of a three-part educational series developed in collaboration with Prudential, publishing through December 2026.

Disclosure: Claims Bureau USA provides investigative support to Prudential as part of Prudential’s anti-fraud program. This article is provided for general educational purposes and is not legal, regulatory, or compliance advice.

 

The long-term care insurance (LTCi) market continues to grow as the U.S. population ages and demand for long-term care services increases. According to the American Association for Long-Term Care Insurance, the number of older adults with disabilities is expected to more than double over time, driving increased utilization of long-term care services and related insurance benefits (American Association for Long-Term Care Insurance [AALTCI], n.d.).

At the same time, long-term care insurers paid approximately $14.1 billion in benefits in 2023, and industry observers project annual benefit payments could approach $40 billion by 2042 (Rupe, 2025). As benefit payments grow, so does exposure to fraud. The Coalition Against Insurance Fraud estimates that insurance fraud costs consumers and businesses more than $308 billion annually across all lines of insurance (Coalition Against Insurance Fraud, n.d.).

One often overlooked tool available to long-term care insurers, third-party administrators, and care management organizations is the U.S. Department of Health and Human Services Office of Inspector General’s List of Excluded Individuals and Entities (LEIE). The LEIE identifies individuals and entities that have been excluded from participating in federal healthcare programs and is updated regularly to reflect changes in exclusion status. Routine screening against the LEIE can help organizations strengthen compliance efforts, support due diligence activities, and reduce organizational risk through more informed hiring, credentialing, contracting, vendor management, and oversight decisions.

 

The Growing Need for Stronger Fraud, Waste, and Abuse Controls

Fraud, waste, and abuse continue to challenge every corner of the healthcare ecosystem, and the long-term care insurance industry is no exception. Carriers, third-party administrators, care management organizations, and network partners all operate in an environment where inadequate screening, improper relationships, or overlooked compliance issues can result in financial losses, regulatory exposure, and reputational harm. They all rely on trusted business relationships that can quickly become liabilities if proper due diligence is overlooked.

Against this backdrop, the LEIE offers a practical and highly effective layer of protection. The LEIE provides organizations with a straightforward way to identify individuals and businesses that have been barred from participating in federal healthcare programs, helping organizations detect potential risks before they affect hiring, credentialing, contracting, reimbursement, or vendor relationships. When incorporated into routine compliance operations, exclusion screening becomes a proactive safeguard rather than a reactive response.

 

Understanding the OIG List of Excluded Individuals and Entities (LEIE)

The List of Excluded Individuals and Entities (LEIE) is a federal database maintained by the U.S. Department of Health and Human Services Office of Inspector General (OIG). It identifies individuals and entities that have been excluded from participation in Medicare, Medicaid, and other federal healthcare programs.

According to OIG guidance, exclusions may result from a variety of integrity-related violations, including healthcare fraud, patient abuse or neglect, certain financial crimes, controlled substance offenses, and other misconduct that calls an individual’s or entity’s trustworthiness into question.

Because the database is publicly available, searchable online, and updated regularly, it serves as a practical compliance resource for organizations looking to build consistent, well-documented screening processes.

 

The Criteria Behind OIG Exclusions

It is important to keep in mind that exclusion doesn’t always mean fraud. The reasons an individual or entity can be placed on the LEIE fall into two categories under federal law: mandatory exclusions, for which the OIG must exclude the person or entity; and permissive exclusions, for which the OIG has the discretion to exclude them.

Mandatory exclusions, as required by law under Section 1128(a) of the Social Security Act, include: Program-Related Fraud; Patient Abuse or Neglect; Felony Convictions Related to Healthcare Fraud; and Felony Controlled Substance Convictions.

Permissive exclusions, as authorized under Section 1128(b) of the Social Security Act, include: Misdemeanor Healthcare Fraud; License Suspension or Revocation; Providing Unnecessary or Substandard Services; Fraud Outside Healthcare; Kickbacks and Illegal Remuneration; Default on Health Education Loans or Scholarships; Controlled Substance License Issues; Exclusion or Suspension by Another Government Agency; False Claims or False Statements; Obstruction of an Investigation or Audit; Failure to Supply Requested Information; Ownership or Management of a Sanctioned Entity; and Other Integrity-Related Conduct.

One of the biggest misconceptions is that everyone on the LEIE committed Medicare fraud. That is simply not the case. Exclusions arise from a wide range of conduct; however, the common thread is that the OIG has determined that the individual or entity should not participate in federally funded healthcare programs for a specified period. This broad scope makes the LEIE much more than a fraud database, instead providing a true comprehensive program integrity resource.

 

Why Exclusion Screening Matters

For insurers and organizations involved in long-term care services, the value of the LEIE extends well beyond regulatory compliance.

From a fraud prevention perspective, exclusion screening helps identify individuals or entities with significant program integrity concerns before they are hired, credentialed, contracted, or reimbursed. From a waste reduction standpoint, it helps avoid unnecessary expenditures associated with doing business with ineligible parties. From an abuse prevention perspective, it strengthens internal controls by identifying relationships that could expose an organization to improper billing practices, weak oversight, or downstream compliance failures.

The OIG also cautions that organizations may face civil monetary penalties if they employ or contract with excluded parties in situations involving federal healthcare program payments. As a result, routine exclusion screening is not simply a best practice; it is an important component of an effective compliance strategy.

 

Integrating Exclusion Screening into Daily Operations

Organizations can integrate LEIE screening into multiple stages of their operations.

Provider-facing teams can incorporate exclusion checks during both initial credentialing and periodic recredentialing for physicians, nurses, assessors, utilization review staff, and other clinical professionals.

Procurement and vendor management teams can apply the same screening standards to third-party vendors that support claims administration, care coordination, case management, and other healthcare-related functions.

Compliance departments can further strengthen oversight by scheduling recurring screenings rather than relying solely on checks performed during onboarding. Because the exclusion list is updated monthly, ongoing monitoring helps organizations identify new risks as they arise.

LEIE Database and Supplement Downloads

When a potential match is identified, organizations should follow a documented verification and escalation process to confirm identity, evaluate potential exposure, and implement appropriate corrective actions when necessary.

 

How Routine Screening Strengthens Compliance and Reduces Risk

The benefits of routine exclusion screening extend beyond meeting regulatory expectations.

A disciplined screening program strengthens organizational integrity, improves operational controls, and reduces the likelihood of entering into business relationships or processing payments involving excluded individuals or entities. It also demonstrates to regulators, clients, and business partners that the organization maintains a proactive and well-governed compliance program.

In an industry built on trust, accuracy, accountability, and responsible stewardship, consistent exclusion screening reinforces regulatory readiness, operational resilience, and organizational credibility.

 

Building an Effective and Sustainable Screening Program

While inarguably valuable, exclusion screening should be viewed as one element of a comprehensive fraud, waste, and abuse prevention program rather than a standalone solution.

The OIG updates the LEIE monthly, making ongoing monitoring essential. The impact there extends far beyond utilizing the LEIE as a one-time exercise. Organizations should also recognize that a name match alone does not establish that an individual or entity is excluded. The OIG specifically advises organizations to verify identifying information before reaching any final determination.

Depending on an organization’s size, geographic footprint, and lines of business, compliance programs may also benefit from reviewing state exclusion lists, licensing board disciplinary actions, sanctions databases, and other regulatory sources to develop a more comprehensive view of potential risk.

 

Looking Ahead: Making Exclusion Screening a Core Compliance Practice

No single tool can eliminate fraud, waste, and abuse. However, the OIG’s exclusion list remains one of the simplest and most effective resources organizations can use to reduce preventable compliance risk.

For organizations operating in the long-term care industry, incorporating routine exclusion screening into hiring, credentialing, contracting, vendor management, and ongoing compliance activities can help strengthen fraud prevention efforts, reduce waste, and identify potential abuse before it develops into a larger (and costly) legal, financial, or operational issue.

Ultimately, effective compliance is about being proactive rather than reactive. By making exclusion screening a routine part of organizational oversight, long-term care insurers can strengthen internal controls, protect the integrity of their operations, and reinforce the trust placed in them by members, providers, regulators, and business partners.

As regulatory expectations continue to evolve, organizations that embed exclusion screening into their governance and risk management frameworks will be better positioned to protect their programs, strengthen operational integrity, and demonstrate a sustained commitment to compliance.

 

Frequently Asked Questions

What is the OIG exclusion list (LEIE)?

The OIG exclusion list, formally the List of Excluded Individuals and Entities (LEIE), is a federal database maintained by the U.S. Department of Health and Human Services Office of Inspector General. It identifies individuals and entities that have been excluded from participating in Medicare, Medicaid, and other federal healthcare programs, and it is publicly available and searchable online.

What is the difference between the LEIE and the OIG exclusion list?

There is no difference. The LEIE is the official name of the database the OIG maintains, and OIG exclusion list is the term most organizations use for it. Both refer to the same publicly searchable record of excluded individuals and entities.

How often is the LEIE updated?

The OIG updates the LEIE monthly. Because the list changes each month, screening only at onboarding leaves gaps, so many compliance programs schedule recurring checks to catch newly excluded parties.

What are the penalties for employing an excluded individual?

The OIG cautions that organizations may face civil monetary penalties if they employ or contract with an excluded party in situations involving federal healthcare program payments. A name match alone does not confirm an exclusion, so organizations should verify identifying information before taking action.

 

About This Series

This article is one of three in a fraud, waste, and abuse prevention series developed in collaboration with Prudential, publishing through December 2026.

For more information:

Stephen Dube
Director, Long Term Care Services, FWA
Prudential
[email protected]

Laura Chew
Vice President of Investigative Services
Claims Bureau USA
[email protected]