What Is Exclusion Screening
As one of the most challenging areas of compliance, exclusion screening is a necessary step for every employer to ensure they are not working with excluded or sanctioned individuals. The Department of Health and Human Services (HHS), Office of Inspector General (OIG) is in charge of enforcing exclusions against individuals or entities. If an individual or entity is excluded, they are prohibited from participating in reimbursements for or from federally funded health care programs. Furthermore,under the Affordable Care Act, an individual or entity excluded in one state is not permitted to participate in federal health care funds in all other states.
Due to OIG increasing enforcement efforts and a possibility for health care organizations that employ excluded individuals to be subjected to costly fines, it is of utmost importance for every health care provider to determine eligibility of their employees to receive payments from government funds.
Types of OIG Exclusions
According to OIG, there are two types of exclusions: mandatory and permissive. Being included in either of them places healthcare providers on the OIG list and prevents them from receiving reimbursement from federal healthcare programs.
Mandatory exclusions are allocated as penalties for healthcare fraud or crimes, patient abuse, or unlawful distribution of controlled substances. This type of exclusion is for a minimum of 5 years and, once it ends, excluded individual or entity needs to apply for reinstatement at the federal and state level.
Permissive exclusions may be issued due to loss of state license to practice, failure to repay student loans, conviction of certain misdemeanors, failure to provide quality care, or other types of misdemeanors. A permissive exclusion can last up to 5 years. Its termination has to be followed by reinstatement process as well.
The OIG does not issue individual warnings or notifications and, in order to verify the status of each employee, employers are required to search the Federal exclusions database and SAM.gov, together with each individual state’s Medicaid Exclusion Database. Different states may require additional searches as well.
The OIG maintains a List of Excluded Individuals and Entities (LEIE) that are excluded from participation in Medicare, Medicaid and other Federal health care programs. An individual or entity listed on the LEIE cannot be employed by a health care provider that receives reimbursement from any Federal health care program. The exclusion list is updated on a monthly basis, and if an individual or entity has been reinstated, they are removed from the list.
The LEIE can be accessed in different ways:
- The OIG provides an Online Searchable Database where the name of an individual or entity can be entered to determine if they are currently excluded. If case of a match, the database allows for verification with other identifiers including an individual’s Social Security Number (SSN), Employer Identification Numbers (EIN), Date of Birth (DOB), and others.
- The OIG provides a Downloadable Database where the entire LEIE can be downloaded. This database does not include SSNs or EINs.
Searching the LEIE cannot be overlooked because healthcare providers who hire an individual on the LEIE may be subject to civil monetary penalties (CMP). To avoid this, healthcare entities need to check the LEIE regularly and ensure that potential and current employees are not excluded.
The General Service Administration’s (GSA) System for Award Management (SAM) contains additional information about individuals and entities that have been excluded or suspended from doing business with the federal government, but is not included in the OIG LEIE. Providers are obliged to check both the LEIE and the SAM to ensure that excluded individuals are not employed. Otherwise they can face significant fines.
State Medicaid Exclusion List
Apart from two federal exclusion databases, individual states maintain a Medicaid exclusion list. To make sure that all available exclusions are monitored and avoid missing excluded providers at a state level, employers need to include state Medicaid exclusion lists in current exclusion monitoring programs.
Violations of the exclusion laws may result in serious fines, such as civil monetary penalties of $10,000 for each item or service provided by the excluded entity or individual or even criminal fines. Undertaking constant OIG background checks can be hard enough, and with health care regulations in a constant state of change, compliance takes more effort and time than ever.
However, exclusion screening does not have to be cumbersome, costly, and time-consuming. Outsourcing the entire process allows employers to replace manual searching and matching with an automated solution that performs thorough and reliable exclusion searches of all available lists and keeps them updated at all times. In addition to this, providers can be immediately notified of any possible issues followed by a resolution of potential matches.
With the OIG continually enforcing fines and penalties for violations, it is necessary for health care organizations to actively follow updates to regulatory requirements and exclusion lists, and regularly monitor their staff for exclusions. Otherwise, they can become non-compliant overnight. Nevertheless, potentially crippling fines can be prevented by automating the entire exclusion screening process. With the right technology, health care organizations can save time, eliminate the risk of being fined, ensure compliance and protect their company from exclusion penalties.