OIG Exclusion List

Your un-official news about the Medicare/Medicaid OIG Exclusion List to help you determine what is fact and what is fiction. We will also review some of the services offered in the industry and answer any questions you might have.

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Health Care License and Certification Verification and Monitoring

Why should I verify and monitor licenses and certifications?

Recently the Florida Attorney General and the Medicaid Fraud Control unit filed charges against a Florida dentist for employing a person to perform duties outside the scope of their license. And, in January of 2013, after self-disclosing, a health care organization in New Jersey agreed to pay $100,000 for violating the Civil Monetary Penalties Law by providing services furnished by an unlicensed and unregistered physician.

Both of these situations highlight the importance of license and certification monitoring as a key factor in meeting current compliance requirements. The Office of Inspector General (OIG) can now fine a health care organization for submitting claims from an unlicensed health care provider. In order to avoid these negative penalties and fines, including license and certification verifications is now key to a successful OIG Exclusion List Monitoring program.

In order for health care organizations to better protect themselves and prevent the employment of unlicensed or sanctioned individuals, continual license and certification verification and monitoring is vital. Failing to verify or monitor licenses and certifications often leads to organizational errors, non-compliance, penalties, and staff shortages. By adopting or maintaining a license and certification verification process as well as implementing continual monitoring, health care organizations are significantly better equipped to remain compliant.

Best Practices:

Utilizing a manual monitoring and verification process, while better than nothing, can often develop inconsistencies and quickly grow unmanageable. An inconsistent and unreliable verification and monitoring system can create legal and safety risks as well potentially lead to fines and other penalties. To avoid these negative consequences as well as save your organization the time and energy of maintaining a manual verification and monitoring process, follow these basic best practices for license and certification verification and monitoring:

Go above and beyond: Instead of getting by with just doing the bare minimum, adopt measures that will make it easy to stay on top of verifying and monitoring licenses. Even if this takes some work on the front end, having a high quality verification and monitoring process in place minimizes risks for missing licenses and certificatations, as well as help identify sanctions and other vital information that could make an individual ineligible for employment.

Consider using an automated system service: Manual verification and monitoring systems are often inconsistent, unreliable, and just unmanageable. Consider purchasing an automated system to manage the tasks of verifying and monitoring licenses and certifications. A professional and high quality service with an established process can help you minimize the risks that result from employee turnover and manually reviewing batch data. A trustworthy vendor with a credentialing and license monitoring system can help streamline these processes and ensure compliance.

Develop and utilize notifications: An automated system can track the status of both medical licenses and certifications and provide alerts regarding expirations, renewals, testing, and continuing education requirements. These notifications will be helpful tools as your organization works to stay on top of various requirements and help you remain compliant.

Ongoing monitoring: By continually monitoring individual and vendor licenses and certifications, health care organizations can maintain trust in their providers and staff caring for patients. At the very least, organizations should consider implementing a quarterly license and certification monitoring system. Ideally, organization should develop a monthly system to minimize risk in meeting compliance regulations. 

A Resource to Learn More >> ProviderTrust Blog

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Monitoring for Sanctions

What are Sanctions?

Sanctions are disciplinary actions levied against a licensed healthcare provider. A sanction from a health care disciplinary or licensing board can have significant consequences depending on the severity of the incident and the due process of the licensing board that gets involved. Sanctions can be levied for a variety of reasons, including fraud, patient abuse, criminal convictions, and even defaulting on a federal student loan.

Before a health care provider receives a sanction, there is a due process hearing in front licensing or disciplinary board. If the ruling results in a sanction, the individual’s license can be restricted, revoked, or suspended among other penalties. This process can take months, sometimes even years to complete.

How do Sanctions relate to the OIG Exclusion List?

Exclusions are a severe form of a sanction, ending with the OIG excluding a provider from participating in Medicaid, Medicare, and other Federal health care programs. A sanction can be an early indicator, depending on the type of infraction, the sanction imposed and/or the conviction of certain felonies, of an impending OIG or State exclusion. In fact, more than 40% of the time, excluded providers on the OIG LEIE get there because their license has been sanctioned or revoked.

Why should I monitor for Sanctions?

It is now a health care organization’s responsibility to self-disclose if they find an excluded provider at their company. As 40% of all exclusions begin with a sanction, being aware of sanctions gives organizations the ability to make decisions before an exclusion is levied. If an organization fails to disclose any excluded providers employed, they face severe penalties. Since 2008, the OIG has fined health care organizations an average of more than $100,000 per excluded employee.

It’s also important to be aware of the due process in states where a sanctioned provider may have moved from in the past. As Section 6501 of the Affordable Care Act dictates that if a provider is excluded in one state, they’re excluded in all states. Thus, in order for a health care organization to be completely equipped to handle OIG exclusion list compliance expectations, they should be continually monitoring for sanctions in all states.

There are about 28 Exclusion lists you should be checking on a monthly basis as well as over 1,600 Sanction lists you should also check to get an early indicator of disciplinary actions against your providers.

Best Practices for Monitoring Sanctions:

Step 1. Start a pre-employment monitoring program

Before hiring new individuals or vendors, screen all potential employees against all available federal and state exclusion and sanctions lists. This screening process should apply to temporary individual providers and vendors as well.

Step 2. Implement a monthly monitoring process

Not only should you screen all new employees and vendors, but consider implementing a monthly monitoring process to check both new and existing employees and vendors on all available federal and state lists. This will ensure your organization is better equipped to address OIG compliance requirements.

Step 3. Consider an automated sanction monitoring program

Manually checking all available federal and state exclusion and sanction monitoring lists can be a time consuming burden on health care organizations. Consider an automated exclusion and sanction monitoring service that would help you meet all compliance requirements and considerably minimize the time and energy spent on these monotonous tasks.  

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Using the SAM Database

What is SAM?

The System for Award Management (SAM) is an official U.S government system that consolidates the capabilities of CCR, FedReg, ORCA, and EPLS. The SAM system was created to help users streamline and integrate processes, eliminate data redundancies, and reduce costs. Functionally, SAM combines the federal procurement systems and the Catalog of Federal Domestic Assistance into one new system. Currently SAM includes functionality from the Central Contractor Registry (CCR), the Federal Agency Registration (FedReg), Online Representations and Certifications Applications (ORCA), and Excluded Parties List System (EPLS).

As the SAM database includes a list of excluded individuals and entities, health care companies must now search the SAM database in order to remain compliant with OIG directives. Although the SAM system was created to consolidate process and eliminate data redundancies, for health care organization the creation of the SAM system had added another step in the process of health care compliance.

How does SAM relate to the OIG exclusion list?

The SAM system includes both individuals and entities found on the OIG exclusion list, therefore it has become necessary for health care organizations to continually check the SAM database. However, the SAM database only includes a fraction of excluded providers on the OIG exclusion list. Thus, health care organization must also continually check the List of Excluded Individuals and Entities (LEIE) as well as the 25 different state lists of excluded providers in order to ensure none of their employed providers are on the OIG exclusion list.

Although the existence of these 27 separate lists of excluded providers presents a challenge for health care organizations, it is vital to continually check each of these lists. Since 2008, the OIG had fined health care providers an average of more than $100,000 per excluded employee. These fines can include $10,000 for each item or service provided by an excluded individual or entity and fines up to tree times that of the amount paid for the services. There is also a possibility that the OIG will exclude any organization that fails to identify excluded employees from federal health care programs.

How do you verify if an excluded person or entity is on the SAM list?

To verify if an individual or entity is listed as excluded on the SAM database, visit www.sam.gov and click on the search records tab.  To execute a search you’ll need:

The address of the individual or entity

The full name of the individual or company

The Data Universal Numbering System (DUNS) number or Commercial And Government Entity (CAGE) code of the entity

*Individuals are not assigned DUNS numbers. To check an for an exclusion for an individual search by typing in the name

If no exclusion record is found, the individual or entity is not listed as an excluded provider in the SAM system. If your search yields a match to an exclusion record, the search result will display an information box with the information of the excluded individual or entity. This information will allow you to verify if the exclusion is a match to your query and detail whether or not the exclusion is currently active.

For more information about the SAM system as well as answers to other frequently asked questions check here.

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ProviderTrust Review

What is ProviderTrust?

ProviderTrust (www.ProviderTrust.com) is an innovative SaaS (Software as a Service) company that provides ongoing solutions to health care organizations’ compliance needs. ProviderTrust enables clients to be complaint with the required HHS/OIG exclusion checks as well as verifies and monitors required licenses and certifications. With ProviderTrust’s comprehensive services, health care providers and organization will be provided with monthly HHS/OIG exclusion list checks, a continual health care sanction screening, and a consistent and automated process for verifying and monitoring licenses and credentials.

ProviderTrust relieves clients of the time consuming burden of manually checking for exclusion lists by providing an automated monthly federal exclusion check of the OIG exclusion list, System for Award Management (SAM), the GSA EPLS debarment list, as well as any available state exclusion lists. 

If ProviderTrust finds any potential matches, they review each match to the client’s employees, providers, and vendors to manually determine the legitimacy of exclusion. 

This process not only helps clients to be compliant with required exclusion checks, but also saves clients’ valuable time and energy previously spent on manually checking these lists.

ProviderTrust also provides healthcare sanction screening as they work to find any disciplinary action or sanction levied against any employees or providers by health care licensing boards across all 50 states. 

Not only will this process find any historical disciplinary actions up to 15 years old, but ProviderTrust is able to monitor for and notify clients of any newly issued sanction as well. As 40% of all exclusions begin with a sanction, ProviderTrust understands a client being aware of sanctions gives them the ability to make decisions before an exclusion is levied.

Finally, ProviderTrust offers primary source health care license verification. ProviderTrust manually verifies all state board issued healthcare licenses when first entered into the ProviderTrust system and re-verifies when a license is renewed. Clients will also be notified via email when a license is expiring as well as given the ability to track any impaired licenses. 

In addition, ProviderTrust will make certain that all health care licenses and certifications required for all positions within the organization are maintained. Clients are able to customize all license and certification policies for employees and providers as well as manage any expiring or missing licenses and certifications. 

ProviderTrust also uses an email alert system to help potentially eliminate lapsed licenses or missing required licenses or certifications. These email notifications will reduce the client’s risk by allowing human resources and compliance to keep employees and providers properly licensed and certified.

Why Should I Use ProviderTrust?

With the passage of the Affordable Care Act on March 23rd, 2010, President Obama put into place a comprehensive health insurance reform that will change the way healthcare is delivered for the foreseeable future. As a part of these changes requirement policies have become extremely complex, and without the right systems it’s nearly impossible to continually check for sanctions and excluded providers as well as monitor every license, certificate, and other required items in your workforce.

For health care providers, not identifying any/all excluded providers employed can have severe consequences. Since 2008, the OIG has fined health care providers an average of more than $100,000 per excluded employee. These fines can include $10,000 for each item or service provided by an excluded individual or entity and fines up to tree times that of the amount paid for the services.

Health Care providers and organizations face significant challenges with compliance policies. Not only do policies change depending on the discipline, unit, facility, and state, but standard human resource and payroll software doesn’t have the specific toolset needed to address these changing policies. As a result, compliance has become a slow, manual, and repetitive process that can easily become overwhelming and unmanageable.

ProviderTrust wants to ensure health care providers and organizations avoid these severe consequences for failing to meet compliance standards. Their innovative technology and dedication to customer service enables their clients to focus less on these time consuming and monotonous tasks, minimize risk, and overcome the compliance challenges they face. 

By using ProviderTrust, healthcare providers and organizations are finally able to concentrate on providing quality care with a qualified and trusted staff. 

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ExclusionCheck.com Review

What is ExclusionCheck.com?

ExclusionCheck.com is the only one-stop-shop that facilitates searches on ALL available federal and state exclusions lists in one place. ExclusionCheck.com was developed the address the need for an easy way to quickly and efficiently check if a health care provider is on the OIG exclusion list.

ExclusionCheck.com is incredibly user friendly. After a quick registration process, users simply go to the home page and search the name of an individual or company to quickly determine whether your employee or vendor is excluded. If there are possible exclusion list matches to your inquiry, ExclusionCheck.com provides a link to the primary source of data to help you verify if the exclusion is a match at the source.

Why use ExclusionCheck.com?

For health care providers, not identifying any/all excluded providers employed can have severe consequences. Since 2008, the OIG had fined health care providers an average of more than $100,000 per excluded employee. T

hese fines can include $10,000 for each item or service provided by an excluded individual or entity and fines up to three times that of the amount paid for the services. There is also a possibility that the OIG will exclude any organization that fails to identify excluded employees from federal healthcare programs.

In order to keep excluded individuals and entities from working in health care facilities and avoid these consequences, most health care providers only check the OIG LEIE to monitor exclusions. 

But the reality is, by only checking the LEIE, you are only checking a fraction of excluded providers! When the OIG audited the LEIE in 2008 they found that a whopping 91% of the providers excluded in the state of Florida failed to appear on the LEIE as well as 79% of excluded providers in New York. Overall, 61% of the providers on individual state lists failed to show up on the LEIE.

Also, Section 6501 of the Affordable Care Act dictates that if a provider is excluded in one state, they are excluded in all states. As of March 3, 2015, 35 states now have their own lists of excluded providers, which do not update to the LEIE. 

Plus, the newly formed SAM database (which includes GSA EPLS) is an entirely separate list of excluded providers and is focused primarily on vendors not updated to the LEIE

SEARCH THE OIG EXCLUSION LIST

  ExclusionCheck.com is the only place that allows you to search all available Federal and State exclusion lists at the same time. ExclusionCheck can help you avoid the negative consequences of failing to identify excluded individuals and entities as well as save you the time and energy previously spent on manually checking these lists. 

Next week, we will review another service called ProviderTrust that automatics the OIG Exclusion List monitoring and verification process. If ExclusionCheck is the Honda of the services, ProviderTrust is the Lexus of OIG Exclusion list services because they offer matched and verified results with monthly monitoring.

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What is an Exclusion and why do I need to search the OIG Exclusion List

The OIG Exclusion List:

With the passage of the Affordable Care Act on March 23rd, 2010, President Obama put into place a comprehensive health insurance reform that will change the way healthcare is delivered for the foreseeable future. As a part of these changes, The Office of the Inspector General (OIG) imposed and maintains a list of exclusions under the authority of sections 1128 and 1156 of the Social Security Act.

The List of Excluded Individuals/Entities (LEIE):

The OIG’s list of excluded individuals and entities exists to provide information regarding excluded providers to the health care industry and the general public. This list includes both individuals and entities currently excluded from participating in all Federal health care programs including Medicare and Medicaid. Any individual or entities that have resolved their exclusion and have been reinstated are removed from the LEIE.

 Before excluding a provider, the OIG sends out a written Notice of Intent to Exclude, which includes the basis for the intended exclusion and an explanation of the potential effect of an exclusion. If the issue remains unresolved after 30 days, the OIG will send a final Notice of Exclusion. The exclusion becomes effective 20 days following this notice is mailed and becomes public information.

 What is an Exclusion?

An exclusion often arises as a result of a sanction (disciplinary action) against a licensed health care provider. Providers can get excluded for committing certain felonies, misdemeanors, or even failing to pay their college loans, but more than 40% of the time excluded providers on the OIG LEIE get there because their license has been sanctioned or revoked. 

Practically, an exclusion prohibits a provider from participating in Medicaid, Medicare, and other Federal health care programs. This means any health care provider that receives reimbursement from any Federal health care program cannot employ an excluded individual or entity. Not only will no payment be made by any Federal health care program for any items or services provided by an excluded individual or entity, but health care providers could potentially face fines among other penalties.

Why do I need to search to OIG Exclusion List?

By law it is a health care provider’s responsibility to self-disclose if you identify an excluded provider. To avoid the negative effects of employing an excluded individual or entity, health care providers should continually search the OIG exclusion list.

Not only should health care providers check for exclusions, but they should also be aware of any sanctioned individuals or entities employed. As 40% of all exclusions begin with a sanction, being aware of sanctions gives you the ability to make decisions before an exclusion is levied. It is also vital to be aware of the due process in states where sanctioned or excluded providers may have moved from in the past as Section 6501 of the Affordable Care Act dictates that if a provider is excluded in one state, they’re excluded in all states.

There are about 35 exclusion lists (Last updated Feb. 2015) you should be checking on a monthly basis as well as over 1,600 Sanction lists you should also check to get an early indicator of disciplinary actions against your providers.

What do I do if I find an excluded provide?

If you identify an excluded individual or entity from the OIG exclusion list, check the Special Advisory Bulletin of the Effect of an Exclusion for guidance. If you are currently employing or have employed the individual or entity while excluded, check the Self-Disclosure protocol.