Exclusion Screening

Exclusion Screening Update on the OIG Enforcement Actions


Emptech's founder, Jeff Aleixo


Jeffrey Aleixo

OIG enforcement actions update exclusion screening

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. And very importantly, most States reported difficulties and sustained challenges obtaining and utilizing quality screening results from Medicare or other States as a substitution for their own results. Thus, the enrollment and revalidation of thousands of high-to-moderate risk providers lead to further OIG enforcement actions.

To solve these problems OIG’s recommendations include enhanced 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.

Recent Actions Taken By the Office of Inspector General

Here is a selection of some recent OIG enforcement. The full descriptions can be found on 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 and 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 have known was excluded from Federal health care program participation. And in Ohio, OhioHealth Corp. agreed 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.
Use this comprehensive guide to learn how to stay ahead of the OIG enforcement actions with effective exclusion screening that meets the OIG strict requirements.

OIG Enforcement Actions Continue

The Office of Inspector General (OIG) of the Department of Health and Human Services continues to coordinate federal, state, and local law enforcement actions with respect to health care fraud and abuse. It has issued its Semiannual Report to Congress, which summarizes key program integrity efforts in the fiscal year 2018.  Notably, during FY 2018, OIG achieved:

  • Expected investigative recoveries of $2.91 billion (compared to $4.13 billion in FY 2017),
  • Criminal actions against 764 individuals or entities for crimes against HHS programs,
  • Civil actions against 813 individuals or entities,
  • Exclusion of 2,712 individuals and entities from federal health care programs.

The report also summarizes various audit reports issued and OIG enforcement actions taken during the period of April 1, 2018, through September 30, 2018.

Maintaining Healthcare Compliance

Having effective healthcare compliance programs is of utmost importance for healthcare providers. Compliance programs help them prevent fraud, waste and abuse, create a mechanism for catching problems early, and provide the basis for a penalty reduction in case of the OIG enforcement actions.

It can be difficult to know whether the compliance program of an organization is effective. For this purpose, they can use the OIG guidance created to help organizations measure the effectiveness of their compliance programs. It includes seven elements of an effective healthcare compliance program and encourages organizations to select the measures that are applicable to them, based on their unique needs, resources, and risks, as part of their ongoing compliance program assessment.

The key element of compliance is for every employer to ensure they are not working with excluded or sanctioned individuals. Healthcare organizations need to determine the eligibility of their employees to receive payments from government funds. Otherwise, they can face OIF enforcement actions and costly fines. However, effective healthcare compliance can be achieved by automating the entire exclusion screening process. Thus, healthcare organizations meet OIG requirements, replace labor-intensive and error-prone procedures with an effective and affordable solution, and stay compliant without any difficulty.

Discover how simple OIG compliance can be with our exclusion screening software that ensures high efficiency and the lowest overall screening cost available.

Editor’s Note: This post has been updated for accuracy and comprehensiveness.

The information contained within this document is general in nature and is not intended and should not be construed as legal, HR, or opinion by Emtpech. Please contact Emptech or another subject matter professional prior to acting on any information provided in this document. We recommend caution when contemplating acting on any information provided in this document as it may not be applicable or suitable for the specific viewer’s needs. Emptech assumes no obligation to update any viewer of any changes in law, rule, or regulation that could affect the information contained herein. Without express written permission from Emptech, no part of this document may be reproduced, retransmitted, or otherwise redistributed in any form or by any means, including, but not limited to photocopying, electronic, facsimile transmission, or using any other information storage and retrieval system.