Sanctions

Disciplinary actions taken against a healthcare provider by a licensing board, government agency, or professional organization, which can include fines, license restrictions, suspensions, or exclusion from federal programs.

Sanctions are disciplinary actions taken against a provider by a regulatory body, licensing board, or government agency. In credentialing, sanctions are a major red flag. Every payer checks for sanctions during the initial credentialing and re-credentialing process. Sanctions can come from multiple sources: your state medical board (license restrictions, probation, suspension, revocation), the federal government (Medicare or Medicaid exclusions, DEA actions), hospital medical staff committees (privilege suspensions or revocations), and professional societies. The most serious sanction is exclusion from federal healthcare programs, which is maintained on the OIG's List of Excluded Individuals and Entities. If you are on the OIG exclusion list, no payer will credential you. Period. You cannot bill Medicare, Medicaid, TRICARE, or any program that receives federal funding. Most commercial payers also will not credential excluded providers. Lesser sanctions like a letter of reprimand from a state board or a fine for a CME deficiency are less severe but still must be disclosed on every credentialing application. The key is disclosure. If you had a sanction five years ago, resolved it, and your license is now unrestricted, most payers will look at the full context. But if you fail to disclose it and they find it during verification, that omission becomes a bigger problem than the original sanction. Payers check for sanctions through several databases: the NPDB, the OIG exclusion list, the SAM (System for Award Management) database, state licensing board records, and sometimes state Medicaid exclusion lists. These checks happen at initial credentialing and again at every re-credentialing cycle.