Exclusion Screening

Outsourcing OIG Exclusion Screening


Emptech's founder, Jeff Aleixo


Jeffrey Aleixo

outsourcing OIG exclusion screening healthcare compliance technology

Every healthcare provider has the obligation to conduct regular OIG exclusion screening of all employees, contractors, and vendors to determine if any individuals or entities are excluded from participating in federal healthcare programs. Failure to do so can result in significant penalties especially as the Office of Inspector General (OIG) continues to broaden its exclusion authority. 

Identifying and properly addressing excluded individuals and entities is of utmost importance for healthcare organizations. This helps them ensure the workplace is safe for patients, customers, and providers. Also, by conducting regular OIG exclusion screening, organizations can reduce the risks of hiring or working with anyone who is excluded. As a result, they reduce instances of fraud, waste, abuse, or other unethical behavior that can become liabilities for the healthcare organization.

Exclusion screening is a complex but at the same time crucial component for successful healthcare compliance. Organizations that conduct OIG exclusion screening in-house are less likely to complete the process as accurately or frequently as needed. Furthermore, it is difficult to conduct successful exclusion screening while remaining compliant with Federal and State regulations. Therefore, healthcare providers should consider outsourcing the entire process. This is how they can achieve simple, accurate, and regular OIG exclusion screening, and meet all necessary requirements without compromising other priorities. 

Why OIG Exclusion Screening Is a Must

Practices that fail to screen individuals and entities against federal and state exclusion databases risk Civil Monetary Penalties (CMPs) and overpayments. Federal and State regulations prohibit payment for any item or service that was provided, directly or indirectly, by an excluded person. According to the OIG, even if a provider is unaware that an individual or entity was excluded at the time the claim was made, such inadvertent violations have to be reported.

Civil fines and monetary penalties assessed by the OIG include the following:

  • $10,000 per each item claimed or services provided;
  • Treble damages;
  • Possible program exclusion of the company;
  • Possible loss of right to bill CMS for services rendered;
  • Possible additional fines for filing false claims under the False Claims Act; and
  • Possible criminal fines and/or jail time.

However, if healthcare providers voluntarily report potential fraud, they can reduce the multiplier to 1.5 times the amount of all damages, in most cases. Healthcare organizations that choose to use the OIG’s Self-Disclosure Protocol can lower their penalties, prevent the costs of going through an investigation and have the matter resolved more quickly.

OIG Exclusion Screening Challenges

The exclusion screening process begins with collecting names and identifying information, such as first, middle, and last names, Social Security Number, date of birth, provider license number, etc. The second step involves screening the collected information against the names and information of excluded individuals or entities included in state and federal exclusion databases. During this process, healthcare providers need to include the OIG List of Excluded Individuals and Entities (LEIE) and the General Services Administration (GSA) System for Award Management (SAM). However, organizations should also screen against state Medicaid databases, especially if they are operating in different states. Also, some state Medicaid programs require providers to screen additional databases depending on the nature of their services. 

In order to ensure efficient OIG exclusion screening, healthcare organizations need to have effective procedures in place for all stages of the screening and name verification process. This includes systemized processes for how to input names and information to initiate the screening process, how to select which databases to screen, and how often to screen. Organizations also need to determine procedures for verifying the results generated from the screening as non-matches, potential matches, or positive matches, and how to follow up on any potential or positive matches of excluded individuals or entities. Thus, OIG exclusion screening may be difficult to balance because organizations need to track the thousands of names that are being screened while maintaining all regular workplace operations. Given the importance and scope of regular exclusion screening, the easiest and most efficient option is to outsource the entire process. 

Use this comprehensive guide to find out what steps to take to prevent working with individuals and entities involved in fraud, waste or abuse and improve your organization’s compliance.

Benefits of Outsourcing OIG Exclusion Screening

OIG exclusion screening can be a complex process to undertake even for those healthcare providers committed to quality care and compliance with the rules. However, the costly and complicated requirements related to the screening of employees, contractors, and vendors can be simplified by outsourcing. This allows healthcare organizations to conduct both single and group name searches against any given federal and state exclusion database, resulting in a thorough investigation and verification process. In addition to this, a team of experts highly trained in conducting efficient screenings remains regularly updated on changes in federal and state screening requirements to provide the most accurate and effective service. 

Outsourcing OIG exclusion screening provides healthcare providers with benefits such as:

  • Exclusion screening software that it is available for them to use at any time. This allows providers to conduct exclusion screening at a time most convenient for them and at any frequency.
  • Multiple search options, such as single name search and group name search, to maximize the organization’s search capabilities.
  • Multiple exclusion databases as a key component of successful exclusion screening. Since individuals or entities may be excluded on multiple databases, screening them all at once saves healthcare providers time and effort.
  • Search records for internal filing and future reference, if needed. Certified reports on the results of exclusion screening should be made part of the organization’s permanent record to prove it was done and to be available in case of an investigation. 

Preventing Compliance Issues Before They Happen

Healthcare providers are placing themselves at risk of hundreds of thousands of dollars in civil monetary penalties by not screening employees, vendors, and contractors for exclusions. Given the increased number of OIG investigations and expanded exclusion authority, healthcare organizations need to actively seek updates to regulatory requirements and exclusion lists as well as to start integrating technology.

OIG exclusion screening is critical to ensure that all individuals and entities associated with the healthcare organization are not excluded from participating in federal health care programs. Outsourcing this process allows healthcare providers to significantly reduce errors, protect patient safety, avoid civil monetary penalties, and maintain healthcare compliance. As a result, organizations can conduct exclusion screening in a more efficient, more reliable, and more carefree way, and make sure they are meeting federal and state regulations without having to disrupt their regular operations. 

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