Author: Brad Moss

Compliance Best Practices

Monitoring excluded providers on an ongoing basis will alert organizations to potential risk of the Office of Inspector General (“OIG”) enforcement.  Once an excluded provider is identified on the List of Excluded Individuals/Entities (“LEIE”) by the OIG, the healthcare organization can take appropriate steps to mitigate and minimize civil monetary penalties (“CMP”) exposure.

Given the nature of the LEIE information, the following best practices will help organizations verify appropriate, actionable data:

  • The LEIE database is updated on a monthly basis so monitoring should occur at least monthly.
  • Because the OIG Database includes only the name known to OIG at the time the individual was excluded, any former names used by the individual (e.g., maiden name, previous married name, etc.) should be searched in addition to the individual’s current name.
  • An individual with a hyphenated name should be checked under each of the last names in the hyphenated name (e.g., Jane Smith-Jones should be checked under Jane Smith and Jane Jones, in addition to Jane Smith-Jones).
  • An organization should maintain documentation of the initial name search performed and any additional searches conducted in order to verify results of potential name matches.
  • Always remember to take the final step of identity verification using the Social Security Number (SSN) for an individual or Employer Identification Number (EIN) for an entity if available. It is not sufficient to simply find a matching name on the LEIE.
  • If a search result does not contain a DOB, UPIN, NPI, EIN, or SSN, it is not available from OIG. Organization may contact the OIG Exclusions Branch to determine if there is any other information available.(1)
  • The OIG recommends that to determine which persons should be screened against the LEIE, the provider should review each job category or contractual relationship to determine whether the item or service being provided is directly or indirectly, in whole or in part, payable by a Federal health care program. If the answer is yes, then the best mechanism for limiting CMP liability is to screen all persons that perform under that contract or that are in that job category.  Providers should determine whether or not to screen contractors, subcontractors, and the employees of contractors using the same analysis that they would for their own employees.(2)

References:

  1. https://oig.hhs.gov/exclusions/tips.asp
  2. https://oig.hhs.gov/exclusions/files/sab-05092013.pdf

OIG Compliance is the Key

When a healthcare organization is found to not be in compliance with laws or regulations, corporate integrity agreements (“CIA”) and civil monetary penalties (“CMP”) may be the unintended consequences.

Beginning in September 1999, the United States Department of Health and Human Services (“HHS”) and the Office of Inspector General (“OIG”) embarked on an initiative to prevent the submission of erroneous claims and combat fraud and abuse in the Federal health care programs through voluntary compliance efforts.  Submitting a false claim, or causing a false claim to be submitted, to a Federal health care program may subject the individual, the entity, or both to criminal prosecution, civil liability (including treble damages and penalties) under the False Claims Act, and exclusion from participation in Federal health care programs.(1)  

The OIG has the authority to exclude individuals and entities from Federally funded health care programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud.  Those that are excluded can receive no payment from Federal healthcare programs for any items or services they furnish, order, or prescribe.  This includes those that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).

The OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (“LEIE”).  Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (“CMP”).  To avoid CMP liability, health care entities should routinely check the list to ensure that new hires and current employees are not on it.(2)

References:

  1. https://oig.hhs.gov/compliance/compliance-guidance/docs/complianceguidance/nhg_fr.pdf
  2. https://oig.hhs.gov/exclusions/index.asp