$25,595 Per Claim: The OIG Civil Monetary Penalty Rate Healthcare Employers Keep Underestimating

The number that healthcare employers keep underestimating is $25,595. That is the 2025 inflation-adjusted maximum civil monetary penalty the OIG can assess, per item or service, when an excluded individual touches a Medicare or Medicaid claim. It is not a settlement number. It is not a worst-case theoretical. It is the per-claim ceiling written into the Code of Federal Regulations, refreshed every January, and it compounds across every line of every claim that flows through an excluded person's hands.

Most operators we talk to are still anchored on the old "$10,000 per item" figure that used to appear in older OIG guidance and in older blog posts. That number is wrong now. The statutory maximum has more than doubled through inflation indexing, and the OIG has been actively using the higher rate in settlements throughout 2024 and 2025. If you are budgeting risk against the old number, you are off by a factor of 2.5.

What the statute actually says

The base authority is 42 USC 1320a-7a, the Civil Monetary Penalties Law. It authorizes HHS to impose monetary penalties, assessments, and program exclusion against any person who, among other things, presents or causes to be presented a claim for an item or service furnished by a person the claimant knew or should have known was excluded from federal health care programs. The statute sets a per-claim penalty amount, and it requires that amount to be adjusted for inflation each year under the Federal Civil Penalties Inflation Adjustment Act.

The actual current dollar figures live in 45 CFR 102.3, the HHS-wide CMP table. That table is what regulators read off of when they calculate exposure, and it is updated through a Federal Register notice every January. The most recent annual adjustment, published January 3, 2025, is the one that produced the $25,595 maximum currently in force for the exclusion-claim penalty.

How the inflation adjustment works

The 2015 Federal Civil Penalties Inflation Adjustment Act Improvements Act required every federal agency to do a one-time catch-up adjustment of its CMPs in 2016, then to adjust them each January thereafter using a formula tied to the Consumer Price Index. HHS publishes the recalculated table in the Federal Register and codifies it at 45 CFR 102.3.

The mechanical effect is that the CMP ceiling rises every year regardless of any new legislation, regulation, or enforcement priority. There is no discretion involved on the agency side. If you settled a case in 2023, the per-claim rate that anchored the negotiation was lower than the rate that applies to a 2025 self-disclosure for the same underlying conduct. Time itself is an aggravating factor.

What triggers the per-claim penalty

The statute is broader than most people read it. The penalty does not require that the excluded individual personally rendered direct patient care. It attaches if the excluded person:

• Provided an item or service that was billed to a federal health care program
• Ordered or prescribed an item or service (a physician ordering labs, imaging, or medications)
• Directed the work of others whose services were billed (medical director, supervisory roles)
• Performed an administrative function that was a necessary prerequisite to a federal claim (billing oversight, utilization review, claims preparation)

See what happens if you employ an excluded Medicaid provider for the full breakdown of what "employ" means under the rules, and what an excluded provider is for the categories of exclusion that put a person on the LEIE in the first place.

The compounding math

$25,595 is the per-item ceiling. The arithmetic is what gets ugly. A single excluded nurse who works one twelve-hour shift on a busy med-surg floor can be associated with dozens of billable items in a single day: medication administrations, vital sign documentation tied to E/M billing, treatments, assessments. Multiply by shifts worked, by months on payroll before discovery, by the number of patients on federal benefits.

The OIG also does not have to assess the maximum on every line. It almost never does. Settlements typically reflect a negotiated per-claim figure well below the ceiling, but the ceiling is what frames the negotiation. When an OIG attorney opens a self-disclosure conversation with a number based on $25,595 multiplied by 6,000 items, the settlement that lands at one-third of that opening number still ruins a fiscal quarter.

What the recent settlements show

The 2024 and 2025 docket of OIG enforcement actions makes the per-item math concrete:

• Sharp Healthcare paid $153,072.64 in December 2024 for employing one excluded nurse. OIG enforcement summary. The full story is in the Sharp settlement breakdown.
• Baptist Health paid $184,758 for similar conduct, an excluded individual on staff whose services touched federal claims.
• The Estates of St. Louis paid $300,000 in June 2024 for employing one excluded charge nurse at a single Missouri nursing facility. OIG enforcement summary. The full case write-up is in the Estates of St. Louis breakdown.
• Lee Health System paid $18,848,530.40 in October 2025, with a portion of the settlement tied to two excluded employees the system knew or should have known were excluded. Full Lee Health analysis here.

The pattern across these is consistent. One or two excluded hires, working in roles that look unremarkable on an org chart, generate enough touched claims to put settlement values into six figures even at modest per-item negotiated amounts. Sharp's $153,072 figure divided by an assumed per-item value of a few hundred dollars implies hundreds of touched items. That is one nurse, on staff, for some bounded number of months.

What this means for budgeting

The asymmetry between prevention cost and violation cost is wider than most boards appreciate. A continuous LEIE and SAM.gov screening program costs a few thousand dollars a year for a mid-size facility. A single missed exclusion that touches a few thousand claims is mathematically capable of producing a settlement larger than a small facility's annual operating margin.

The compliance officer's job is not to eliminate exclusion risk. It is to generate the audit trail showing the screening was done and the result was clean on the dates the federal claims were filed. Monthly LEIE screening, monthly SAM.gov screening, and continuous license status monitoring are the documentation regime that converts a discovered exclusion from a catastrophic CMP exposure into a routine HR remediation. See what the OIG exclusion list is, how OIG, SAM.gov, and NPDB compare, and what continuous license monitoring actually catches.

The number to remember

$25,595, per item or service, for 2025. Indexed up next January. Multiplied across every line your excluded employee touched. That is the math the OIG opens every CMP negotiation with, and it is the number a board needs in front of it when it decides whether monthly screening is a budget priority.