Earning an exclusion from the Department of Health and Human Services Office of Inspector General (OIG) can cause the end of a career or business in the healthcare industry. Once excluded or sanctioned, an individual or entity is prohibited from receiving payment or reimbursement from any Federal healthcare program, which includes Medicare and Medicaid. The payment prohibition affects the person, anyone who contracts or employs the excluded person, and health providers that service the said person.
If a company is found to be using federal healthcare funds to service or pay an excluded individual, it can face hefty fines and civil monetary penalties. These include $10,000 for each claimed item or service furnished to the individual, up to 3 times the amount claimed for each item or service, and the possibility of also getting excluded. In order to avoid these, it is a must for companies, especially healthcare providers, to regularly and diligently screen their employees, contractors, and subcontractors for exclusions and sanctions. Implementing a set of exclusion screening best practices can help companies simplify the entire process and take advantage of such a proactive approach.Find out about differences between the OIG and SAM exclusion list and meet all healthcare compliance requirements.
Exclusion List Database
Before the screening, providers need to go through the exclusion lists managed and maintained by the entities that give out the sanctions, which is either the OIG or a state Medicaid agency. The OIG’s List of Excluded Individuals and Entities (LEIE) is the primary federal-level list that should be consulted when searching for currently excluded individuals. Providers should also check the General Services Administration’s (GSA) System for Award Management (SAM) if they want to see the list of companies and individuals that have been barred from receiving federal contracts. The LEIE is updated every month while the GSA-System for Award Management, which includes the EPLS, is typically updated every week.
Then, there are the state-level exclusion lists that are separately maintained by different states. Ideally, the names included in the state-level lists should also be found in the LEIE, but this is not always the case. As such, it is best to also consult the state’s exclusion list whenever providers are screening a person. How often these lists are updated depends on the state.Use this detailed guide to learn what exclusion screening best practices are and start benefiting from an advanced and proactive approach.
Whose Responsibility Is Screening?
Any person who provides any service or item that is being paid in part or in full by any federal healthcare program must be screened. This may include employees, contractors, subcontractors, and even the people employed by contractors. Employees should be screened by the human resources department. Screening physicians falls in the hands of the credentialing committee. Prior to contracting, the procurement department should also conduct its own screening to ensure that their contractors and vendors are not in any of the sanction lists. A contractor can screen their employees, but the result of the screening should always be validated by a company’s compliance officer.
The sheer number of names to be screened and the different formats, update schedules, and features of the sanction lists can make manual screenings a complicated and time-consuming task. Because of this, many companies employ the services of agencies that specialize in background searches. However, this can be a costly choice, especially for large companies with more than a hundred employees. Capitalizing on exclusion screening technologies is also an option for companies that want cost-effective and quick searches with reliable results. But if companies are conducting manual screenings, it is important to incorporate the following exclusion screening best practices:
- Screening Frequency
The OIG updates the LEIE list every month and recommends that providers screen their employees on a monthly basis. Adhering to this guideline lowers financial risk as it allows the company to detect sanctioned employees or contractors as early as possible and minimize the amount of potential take backs and fines from CMS. For larger companies where a monthly screening will prove to be too costly, a regular automated screening is highly recommended. In addition, screening employees, physicians, and contractors or vendors before getting them on board is also a must.
- Name Matching
When doing manual searches, exact matches of first and last names will only get you so far. One of important exclusion screening best practices is to ensure the reliability and accuracy of the search. Therefore, healthcare providers have to consider name variations, maiden names, hyphenations, international names, and even spelling errors. In fact, it is not entirely impossible that some of the names in the sanction lists have been misspelled. This, however, is not an excuse for failing to detect an excluded individual. Some lists, like the LEIE, have a validation mechanism that uses the employee’s Social Security Number (SSN). But for lists that do not offer this feature, you can try matching other available details, such as the individual’s birthdate, state, or employer name.
- Vendor Matching
Compared to matching individuals, matching vendors can be a bit trickier. This is because aside from the vendor name and Employer Identification Number (EIN), there is not a lot of information you can use for the searches. What you can do is limit the number of your search results by omitting common words, like healthcare and America, from the keywords. In order to minimize the financial risks, you can also choose to prioritize contractors that get paid beyond a certain amount.
Finally, as one the most important exclusion screening best practices, documentation plays an important role in case providers do find a match or a probable match, or in case of an audit. It is a good idea to keep screenshots, documents, and time stamps of the names that have already been reviewed, the exclusion list the names were reviewed against, and the process of determining a match.
Complying with healthcare exclusion screening guidelines set by the OIG remains a challenge for many companies and healthcare providers. However, it is a necessary step towards minimizing misconduct, avoiding costly fines, and remaining in good standing with the OIG. At times, your searches can be limited by the available information, the search features can be used to filter the exclusion list or the sheer number of resulting matches. When these happen, it is advisable to approach the employee or contractor in question for an honest discussion or ask your company’s legal counsel for other options. In addition to complying with exclusion screening best practices, exclusion screening technology allows employers to make sure that every single time they conduct a search, they are doing it with due diligence and utmost care. Technology streamlines the screening process for companies, making it easy to screen thousands of employees monthly, automatically.
Editor’s Note: This post has been updated for accuracy and comprehensiveness.