The U.S. Department of Health and Human Services (HHS), Office of the Inspector General (OIG) is established to protect HHS programs and their recipients. The OIG aims to find and prevent fraud and abuse within HHS programs and can exclude certain individuals or healthcare organizations from providing services under federally funded healthcare programs.
Healthcare providers that arrange or contract with excluded individuals can be subject to a wide range of serious consequences. Thus, they need to take the necessary steps to protect their organizations and prevent OIG exclusions from federal healthcare programs.
What Are OIG Exclusions from Federal Healthcare Programs?
An OIG exclusion is a remedial punishment that prohibits an individual or entity from being reimbursed by or participating in federal healthcare programs. The OIG has sole authority when deciding to exclude individuals or entities, and can do so under a number of mandatory and discretionary circumstances.
OIG exclusions from federal healthcare programs can happen for a variety of reasons, including:
- Medicare or Medicaid fraud,
- Offenses related to the delivery of items or services under Medicare, Medicaid, State Children’s Health Insurance Program (CHIP), or other state healthcare programs,
- Patient neglect or abuse,
- Felony convictions for other healthcare-related fraud, theft, or other financial misconduct,
- Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances,
- Misdemeanor convictions related to healthcare fraud other than Medicare or a state health program,
- Fraud in a program funded by any federal, state, or local government agency,
- Misdemeanor convictions relating to the illegal manufacture, distribution, prescription, or dispensing of controlled substances,
- Suspension, revocation, or surrender of a health care license for reasons bearing on professional competence, professional performance or financial integrity,
- Provision of unnecessary or substandard services,
- Submission of false or fraudulent claims to a federal healthcare program,
- Engaging in illegal kickback arrangements,
- Defaulting on a health education loan or scholarship obligations, and
- Controlling a sanctioned entity as an owner, officer, or managing employee.
Some of these reasons lead to mandatory exclusions, where the OIG is required by law to exclude the individual or entity from federal healthcare participation. Others, known as permissive exclusions, can be made at the discretion of OIG.Use this detailed guide on exclusion screening to help your healthcare organization avoid costly penalties and streamline compliance.
Consequences of OIG Exclusions from Federal Healthcare Programs – Payment Prohibition and Civil Monetary Penalties
The principal consequence of OIG exclusions from federal healthcare programs is that payment is prohibited for items or services that an excluded individual or entity provides, orders, or prescribes. This payment prohibition extends to anyone who chooses to employ or contract with an excluded individual or entity. Furthermore, payment of an excluded individual’s salary, fringe benefits, or expenses, directly linked to federal healthcare program funds, is also prohibited.
Healthcare providers who violate this prohibition are required to pay back all federal health care program funds inappropriately received and may also be subject to civil monetary penalties. Civil Monetary Penalties apply to any individual who provides, orders or prescribes items or services while excluded and may also be enforced against healthcare providers that employ or contract with excluded individuals or entities. Civil Monetary Penalties can reach up to $10,000 for each item or service furnished by the excluded individual or entity, plus three times the amount claimed for that item or service.
There are situations in which a healthcare provider who receives federal healthcare program funds may employ or contract with an excluded individual. This happens when the healthcare provider is able to:
- pay the excluded individual or entity exclusively with private funds,
- pay the excluded individual or entity from other non-federal payment sources, or
- the services provided by the excluded individual or entity, relate only to non-federal healthcare program patients.
Taking Precautions to Avoid OIG Exclusions
Employing or contracting with an excluded individual or entity can hold serious risks, in both money and reputation, for an organization and the patients they serve. Therefore, healthcare organizations should make OIG exclusions part of their screening of all candidates, new hires, and current employees.
Since the OIG maintains a list of excluded individuals and entities (LEIE), healthcare providers can determine if current or future employees are excluded by searching the list and ensure liability is averted. However, to effectively prevent OIG exclusions from federal healthcare programs, healthcare organizations should conduct regular exclusion checks before and after an employee has been hired. Since the LEIE is updated monthly, the OIG recommends conducting exclusion screening with the same frequency to minimize risk.
While screening the OIG exclusion list is important, an advanced exclusion screening solution can streamline this process and identify individuals who have been excluded, terminated, sanctioned, or debarred from the various federal and state programs. Thus, healthcare organizations improve the accuracy and speed of the process and ensure accurate screening and reporting results. As a result, they can prevent OIG exclusions from federal healthcare programs, protect their reputation, preserve patient safety, and ensure compliance with federal guidelines.