Monthly exclusion screening — workforce, medical staff and contractors

Template version 2026-10-06 · for: Hospitals and health systems; any provider billing federal health care programs · owner role: Compliance Officer (owner); HR and Medical Staff Office (data owners); AP for contractors · adopted by organization effective date . Editable .txt · JSON

Template. Written against the public text of the standard cited; the organization adopts, edits and owns it as its protocol. Every threshold, identity, hold or disclosure decision belongs to the organization. We report the findings against the protocol — counts, dates, states — nothing more. Not legal advice, not a compliance determination, not a consumer report.

Standards served

HHS-OIG General Compliance Program Guidance (Nov 2023) — exclusion screening at hire/contract and monthly — https://oig.hhs.gov/compliance/general-compliance-program-guidance/
OIG Special Advisory Bulletin on the Effect of Exclusion (2013) — https://oig.hhs.gov/exclusions/special-advisory-bulletin-and-other-guidance/the-effect-of-exclusion-from-participation-in-federal-health-care-programs-2013/
42 CFR 1003 — civil monetary penalties for items or services furnished by an excluded person — https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1003
42 CFR 455.436 — the monthly LEIE/SAM cadence states apply, which payers pass down by contract — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-E/section-455.436

Scope

Every employee, credentialed and privileged practitioner, locum, student/trainee with patient contact, volunteer with patient contact, board member, and every contractor or vendor whose items or services are billed to or reimbursed by a federal health care program.

Frequency

At hire, credentialing or contract; then monthly, on a fixed calendar day, for the whole roster.

Procedure

Build the roster file by the ___ of each month: legal name as it appears on the W-4/license/contract, NPI where one exists, role, department, hire or contract date. HR, the Medical Staff Office and AP each own their section; the Compliance Officer owns the merge.
Run the roster against OIG LEIE, SAM.gov exclusions, and the Medicaid exclusion list of every state the organization operates or bills in. Keep one dated record per name per month that shows, for each source: the file date, the read time, the exact name or NPI used, the rows as printed, and any source that did not answer.
Review every row printed under a roster name. A row under the same printed name is a candidate, not a finding: confirm or rule out identity by NPI, date of birth, address or license number on the agency's record. Record who decided, when, and on what.
Where a source did not answer, the name's month is incomplete: re-run that source within ___ business days and attach the second read. Never record 'no results' for a source that was not read.
For any confirmed match: follow the Exclusion Response procedure (HOSP-07). Billing, employment and disclosure decisions are made there, by the people that procedure names, not by the screener.
Retain each month's records (receipts, review notes, decisions) for the period set in HOSP-08. File the month's summary (measures below) with the Compliance Committee packet.

Findings reported — computed from your own records; the threshold is your protocol's

Finding	Computed as	Data source	Threshold
Roster coverage	names screened this month ÷ names on the HR + medical staff + contractor rosters at month end	roster files; receipts or results CSV (status column)	your protocol
Time to first screen	days from hire/credentialing/contract date to first receipt date, per name; report median and maximum	HR/MSO dates; receipt created_at	your protocol
Source completeness	names whose month has every source answered ÷ names screened; and did-not-answer rate per source	receipt did_not_answer lists; results CSV did_not_answer column	your protocol
Candidate resolution time	business days from a same-name row appearing to a recorded identity decision; median and maximum	review log	your protocol
Changed lines reviewed	rows whose month-over-month diff shows a changed line, and the share reviewed before month end	results CSV changed_lines; ENTITY_STATE_DELTA events	your protocol
Evidence producibility	minutes to produce the dated record for a randomly sampled name from a past month (test quarterly)	HOSP-08 drill	your protocol

Records

Record	Kept by	Retention
Monthly roster file	HR/MSO/AP → Compliance	per HOSP-08
One dated receipt per name per month (sources, file dates, rows, did-not-answer, hash)	screening system	per HOSP-08
Candidate review log (who/when/basis)	Compliance Officer	per HOSP-08
Monthly measures summary	Compliance Officer	per HOSP-08

What this procedure does not decide

Whether a same-name row is your person; whether to suspend, terminate, bill, refund or disclose; whether any penalty applies. Those are decided under HOSP-07 by the roles it names, with counsel.

Change log

Date	Change
2026-10-06	First issue.
date	adopted / edited by name

Other templates: 02 · 03 · 05 · 06 · 07 · 08 · 09 · 10 · 01 · Duty Sheets (one page per rule, generated on any receipt) · our own procedures · 2026-10-25