Exclusion Screening

Emptech Exclusion Screening Update: News from the Office of Inspector General, U.S. Dept. of Health & Human Services



Jeff Aleixo

Providers Terminated in One State Continue to Participate in Other States…

In May, 2016 testimony to Congress, the Department of Health and Human Services Assistant Inspector General Ann Maxwell reported on a study the OIG conducted in 2014 that revealed several shortcomings with respect to the extent to which States are utilizing risk-based screening of high-and-moderate risk providers. The outgrowth of that study is included in OIG’ s 2017 Compendium of Unimplemented Recommendations.

The study found that many States have not fully implemented fingerprint-based criminal background checks, and site visits (guidance that CMS initially issued in 2015). And very importantly, most Sates reported difficulties and sustained challenges obtaining and utilizing quality screening results from Medicare or other States as substitution for their own results. This has resulted in the enrollment and revalidation of thousands of high-to-moderate risk providers.

To solve these problems OIG’ s recommendations include stepped-up CMS support of States in their efforts to implement fingerprint based technology; to increase and improve site-visits; to ensure the quality and accessibility of substitute screening data; and to access and utilize a fully functioning central system for States to submit and access screening results from other States. Thus the OIG recommends that CMS should require each State Medicaid agency to report all terminated providers. And this points to the reality that the extreme importance of advanced, methodical, and frequent exclusion screening extends to every level of engagement with all participating individuals and entities.

On the enforcement front here’s a selection of some recent actions taken by the Office of Inspector General. The full descriptions can be found on the OIG’ s official website.

– An unlicensed New Jersey dentist agreed to a $1.1 million dollar fine and a 50-year exclusion from Federal health care program participation for assuming the identity of a licensed (later deceased) dentist and presenting Medicaid claims for services using that dentist’s identity. The allegation included that the unlicensed dentist perpetrated the fraud from late 2005 to late 2012.

– Two cases in February of this year were resolved by way of self-disclosure. In Rhode Island, Orchard View Manor agreed to pay over $61,000 dollars for allegedly employing an individual that it knew or should’ve known was excluded from Federal health care program participation. And in Ohio, OhioHealth Corp. agree to a CMP of over $231,000 dollars for allegedly employing three excluded individuals.

– In April this year Pafford Medical Services Inc. in Arkansas agreed to a CMP fine of over $390,000 dollars for employing an excluded individual.

Best practices call for minimum monthly screening of all individuals and entities that a provider does business with. Emptech provides high efficiency and ensures full compliance with the lowest overall screening cost available.

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