Response to a confirmed exclusion, debarment or sanction match

Template version 2026-10-06 · for: Hospitals, health systems, practices — the Compliance Officer's procedure once identity is confirmed · owner role: Compliance Officer (owner); General Counsel (decision partner); HR / MSO / AP / Revenue Cycle (actions) · 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

OIG Special Advisory Bulletin — effect of exclusion; payment prohibition and CMP exposure — https://oig.hhs.gov/exclusions/special-advisory-bulletin-and-other-guidance/the-effect-of-exclusion-from-participation-in-federal-health-care-programs-2013/
OIG Health Care Fraud Self-Disclosure Protocol (2021) — https://oig.hhs.gov/compliance/self-disclosure-info/health-care-fraud-self-disclosure-protocol/
42 CFR 1003 — civil monetary penalties — https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1003
60-day overpayment rule — 42 CFR 401.305 — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-401/subpart-D/section-401.305

Scope

Any roster name whose same-name row has been confirmed as the person or entity by the identity procedure in HOSP-01/02/03.

Frequency

Immediately on confirmation; this procedure is a timed sequence.

Procedure

Day 0: Compliance Officer logs the confirmation (who confirmed identity, on what agency fields), preserves the dated record that printed the row and the identity evidence, and notifies General Counsel. Privilege decisions are counsel's.
Day 0–1: the role owner (HR / MSO / Supply Chain) takes the interim action the organization's policy prescribes — written here: ___ — and records it. The screening record did not prescribe it; this procedure does.
Day 1–10: Revenue Cycle and Finance quantify items or services furnished or ordered by the excluded party during the exclusion period and billed to federal programs; Counsel evaluates the 60-day rule clock and the Self-Disclosure Protocol. Record the analysis and the decision, whichever way it goes.
Day 10–30: execute the decisions (refund, disclosure, personnel/contract action); update the roster; record completion dates.
Root cause: how did the party get on the roster or stay on it — hiring gap, screening gap, identity gap, source silence? Write the procedural change and its notation in the affected template.
Report to the Compliance Committee and Board per the compliance program charter; keep the full file per HOSP-08.

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

Finding	Computed as	Data source	Threshold
Identity-to-counsel time	hours from identity confirmation to counsel notification	response log	your protocol
Interim action time	hours from confirmation to recorded interim action	response log	your protocol
Quantification time	days from confirmation to completed billing analysis	response log	your protocol
Root-cause closure	confirmed matches with a written procedural change and notation ÷ confirmed matches	template change logs	your protocol

Records

Record	Kept by	Retention
Response log (timed steps, decisions, basis)	Compliance Officer	per HOSP-08; counsel decides privilege
Billing analysis	Revenue Cycle / Finance	same
Disclosure/refund correspondence	Counsel	same

What this procedure does not decide

Whether exclusion applies to the services, whether a refund or disclosure is owed, what personnel action to take — counsel and the organization decide. The screening record is evidence of what the file printed and when it was read.

Change log

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

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