Exclusion Screening

Avoiding Mistakes in Exclusion Screening Process


Emptech's founder, Jeff Aleixo


Jeffrey Aleixo

avoiding mistakes exclusion screening process healthcare compliance

All healthcare businesses and providers are subject to a complex network of laws and rules. Failing to comply with any of these regulations can result in fines, loss of program eligibility, and even federal imprisonment.

The exclusion screening process helps organizations and providers determine if any of their employees are included in exclusion lists. The Office of Inspector General (OIG) requires regular exclusion screening and follows strict guidelines to ensure that information regarding each individual or entity is accurate. Therefore, exclusion screening should be a high priority for every healthcare organization.

However, with so many compliance issues for health care providers to keep track of, it is not surprising that mistakes in the exclusion screening process are common. The OIG recognizes that mistakes happen, but the aim of an effective healthcare compliance program is to implement controls to reduce the possibility of errors and to make sure that if mistakes do happen, they are quickly identified and corrected.

Find out what types of misconduct can trigger OIG exclusions, how to remain compliant and prevent enduring an OIG investigation.

What to Do When an Employee Is Excluded

Failure to screen an individual that happens to be excluded could result in thousands of dollars in monetary losses, suspended participation in federal programs like Medicare and Medicaid, placement under a Corporate Integrity Agreement, or criminal fines. All of this can lead to the loss of trust and lasting damage to an organization’s reputation. This is why healthcare organizations have to be meticulous in achieving and creating healthcare compliance and to take all the necessary steps to avoid mistakes in the exclusion screening process.

Employing an individual that is excluded puts a health organization at risk of facing serious consequences. One of the first things that healthcare providers need to do after finding a match is the process the termination of the excluded person. The longer that individual stays employed and the more resources they receive, the bigger the fine can be. So, once a match is confirmed, it is necessary to determine how much money or items have already been billed to federal healthcare programs because of the excluded individual.

After gathering necessary information, healthcare providers need to issue a letter of disclosure to the OIG and also notify patients that were involved with the excluded person. Every healthcare organization and provider has the responsibility to ensure that resources allocated to providing healthcare are used responsibly. The proper exclusion screening process helps healthcare organizations avoid hefty penalties, but also keeps medical resources safe from fraud and abuse.

Use this detailed guide to find out what steps to take in order to avoid mistakes in exclusion screening process and maintain effective healthcare compliance.

Common Mistakes in Exclusion Screening Process

Many health care organizations employ hundreds or thousands of workers, which may increase the chance for a lapse in screening for exclusions and costly mistakes due to human error. For these reasons, it is easy to oversee if an individual or entity is excluded.

Furthermore, checking exclusion lists may not be enough to protect health care organizations from serious risks and penalties. The OIG’s List of Excluded Individuals and Entities (LEIE), the General Services Administration’s (GSA) System for Award Management (SAM), and state exclusion lists are updated occasionally, leaving gaps in time between when an individual is excluded and when this information is added to the lists.

Mistakes in the exclusion screening process can lead to significant fines and other types of penalties. According to the OIG, failure to implement effective controls designed to identify, detect and prevent mistakes in the exclusion screening process may itself be viewed as evidence of fraudulent intent.     

However, there are many ways to help ensure the accuracy of a health organization’s exclusion screenings. Most importantly, healthcare providers need to be aware of the following common mistakes that can lead to inadequate exclusion screening process:

Failing to Keep up with Healthcare Regulations

Federal, state, and even local legislative bodies and regulatory agencies establish various rules intended to ensure that medical professionals adhere to high standards. Healthcare regulations are complex and constantly change. Thus, to ensure that the facilities they work for operate within the law, healthcare providers need to stay up to date with all of the regulations.

Not Using Updated Exclusion Lists

Using the same version of exclusion lists means that healthcare providers are probably working with outdated and incorrect data. Healthcare providers have a responsibility to make sure that the exclusion screening process is done by using the most recent version of federal and state exclusion lists. For example, an excluded individual might have already been cleared in the most recent version of the LEIE. On the other hand, individuals that were not in the LEIE before might have been included in the most updated version of the list.

Not Performing Background Checks

In addition to checking exclusion lists regularly, it is highly advisable to perform background checks on employees and contractors before hiring them. Thorough background checks during the hiring process can help healthcare providers find out excluded persons even before they have the chance to get employed by the healthcare provider. This is how they can simplify the exclusion screening process and prevent excluded individuals to work for healthcare organizations.

Failure to Use Exclusion Screening Technology

The best way for healthcare organizations to perform checks with minimal risks of inaccuracies is to use software designed to automate and enhance the effectiveness of the exclusion screening process. Advanced exclusion screening solutions can automatically send email notifications in case of any matches with the most recent version of exclusion lists. This allows healthcare providers to address the issue as soon as possible while minimizing potential penalties and fines.

Healthcare Compliance Standards

Despite being found out and prohibited from taking part in healthcare programs, a number of excluded individuals still find different ways of working for healthcare organizations, leaving them open to potential violations. Also, the intricacies of today’s healthcare regulations require healthcare providers to be familiar with a diverse set of rules. Otherwise, they can easily make costly mistakes. In order to strengthen the exclusion screening process and reduce the risks of non-compliance and mistakes, healthcare organizations should consider using an automated web-based exclusion screening platform. This allows them to get timely notifications for any positive matches related to criminal activity or sanctions and exclusions violations.

Every effective healthcare compliance needs to be based on a constant and thorough exclusion screening process. There is no question that there are costs associated with implementing compliance standards and technology to prevent violations. However, there could be a much greater cost of not doing so. While exclusion lists show names of excluded individuals, it does not mean that healthcare organizations that employ those individuals are in the clear. Contracting or employing the services of an excluded individual or entity can result in heavy penalties. This is why the regular exclusion screening process is of utmost importance for all healthcare organizations.

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