Healthcare compliance is a constant process of abiding by legal, ethical, and professional standards applicable to healthcare organizations. Having an effective compliance program in place is necessary since hiring an employee excluded for posing risks to patient safety or financial integrity extends those risks to healthcare providers as well. Additionally, this exposes them to overpayments when receiving reimbursements from federal healthcare programs, therefore negatively affecting patient care and the overall bottom line of their business.
The key component of healthcare compliance is cross-checking and monitoring exclusion lists on a regular basis. Even though this process can be overwhelming and time-consuming, employers need to screen employees and contractors against two main federal exclusion lists and available state Medicaid exclusion lists. The first step in successfully ensuring that excluded parties are not providing any services is that employers understand differences between the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) and the General Services Administration’s (GSA) System for Award Management (SAM).Find out how to achieve effective compliance and make sure you stay acquainted with every exclusion list with this comprehensive guide on exclusion screening.
DIFFERENCES BETWEEN EXCLUSION LISTS
The OIG Exclusion List
The LEIE is a list of all individuals and entities currently excluded by the OIG. It is the providers’ obligation to regularly check the OIG exclusion list to ensure that new hires and current employees are not on it. The list contains the name of excluded individuals or entities at the time of the exclusion, the provider type, the authority under which the individual was excluded, and the state where the excluded individual resided at the time of the exclusion. The OIG exclusion list is updated on a monthly basis, and if an individual or entity has been reinstated, they are removed from the list.
By accessing the OIG’s website, healthcare organizations can search up to five names of individual providers and vendors. In case of a possible match, healthcare providers can add additional information to try to determine or confirm the results. Organizations can also use a downloadable file to compare in-house databases with the OIG exclusion list.
Searching the LEIE is necessary because healthcare providers who hire an excluded individual or entity may be subject to civil monetary penalties (CMP). Providers may face CMP exposure if they submit claims to a federal healthcare program for items or services provided, directly or indirectly, by excluded individuals. To avoid potential CMP liability, providers need to check the OIG exclusion list prior to employing individuals or entities together with conducting regular checks to determine the exclusion status of current employees and contractors.
SAM Exclusion List
The aim of the General Service Administration (GSA) is to prevent fraudulent handling of the healthcare system and other government entities by maintaining a database of parties excluded from Federal procurement. The GSA’s System for Award Management (SAM) incorporates the following databases:
- Central Contractor Registry (CCR),
- Federal Agency Registration (Fedreg),
- Online Representations and Certifications Application (ORCA),
- Excluded Parties List System (EPLS).
If a possible record is found on the SAM exclusion list, providers are instructed to go to the government agency directly to verify. If the excluded party is an entity, providers need to know the Dun & Bradstreet number. If the exclusion is for an individual, four additional steps are necessary to complete the process of verification.
OIG vs. SAM Exclusion List
OIG’s LEIE and GSA’s SAM exclusion lists are created by different agencies and have their own administrative process. Even though there is a significant overlap between them, they are different. Searching for excluded individuals via the SAM exclusion list can be more complicated because the database does not have license information or NPI records like the OIG exclusion list. Furthermore, SAM.gov has no authority to fine an organization since it is a procurement repository.
Staying ahead of Exclusions
The OIG constantly expands its exclusion authority and without active research of regulatory requirements and exclusion lists, healthcare organizations can easily face compliance issues. The best practice for finding exclusions is to search the SAM exclusion list together with the OIG exclusion list and get all available information on excluded, sanctioned, and debarred individuals or companies. In addition to this, providers need to stay in accordance with their state’s requirements and check their own Medicaid exclusion lists. According to Section 6501 of the Affordable Care Act (ACA), if a provider or entity is excluded under any state Medicaid database, that provider or entity should be excluded from participating in all states.
Checking all employees and entities against every available exclusion list on a regular basis can be difficult and time-consuming, especially for health care organizations that employ and contract hundreds of individuals. However, many of these checks from multiple sources can now be automated, saving healthcare providers critical time and money while also reducing the risk of non-compliance. An exclusion screening solution ensures screening of all employees, vendors, and subcontractors against the OIG exclusion list and SAM exclusion list prior to hiring or contracting, followed by regular screenings afterward. As a result, healthcare providers are immediately notified about sanctions and disciplinary actions against individuals and entities, allowing them to meet all compliance requirements and considerably minimize the time and money spent on these arduous procedures.