Tag: LEIE

Let’s Talk about Primary Source Data

What is a Primary Source?

A Primary Source is the original source repository or the source that legally issue licenses, discipline, education, training, or examination. A couple of examples of this in our industry are:

California Board of Registered Nursing
Office of Inspector General, U.S. Department of Health and Human Services (OIG)
Pharmacy Technician Certification Board (PTCB)
Centers for Medicare and Medicaid Services (CMS)

What is a Primary Source Data?

Primary Source Data is the license, certification, or disciplinary data directly from the original source. This means the data we collect is directly from the primary source. This data includes exclusion information, opt-out affidavits, license issuance, and disciplinary records. Another caveat to primary source data is we do not change, adjust, or modify the record found at the primary source.

Why is Primary Source Data Important?

Primary source data is important to your company as a way to confirm that your employee can be authorized to work for your facility.

The OIG has the authority to exclude individuals and entities from participation in federal healthcare programs. Any organization or individual who hires excluded parties may be subject to civil monetary penalties (CMP). To avoid these penalties, the LEIE recommends (as a part of the Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs) that you check their database upon hire, and on an ongoing monthly basis.

Primary Source data is not only important to us, it’s important to accrediting bodies (i.e. The Joint Commission, URAC) and exclusion bodies (i.e. OIG, GSA).

Risk: It’s All About Time!

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Medical Provider data with regards to Medicare and Medicaid exclusions can be tricky from a timing perspective. Even though the Office of Inspector General (OIG) with the List of Excluded Individuals and Entities (LEIE) were created to attack the ever changing problem of Medicare Fraud, it can often be a trailing indicator. There are rules of inclusion that require the OIG to follow a process that often takes time. Once a name or entity is entered into the data set, it is only a matter of checking the names against the dataset either through the government website, downloading the data or using a Consumer Reporting Agency (CRA) or similar service.

The OIG is focused on this issue and does a good job to keep the data up to date as possible and it is a large effort indeed considering the estimate of Medical licensed professions is just under 12 million according to the most recent estimates.

But what about the risk of those organizations that hires or does business with individuals or entities who have been convicted of a crime or state boards who have taken action but the license is unaffected or the OIG has not issued an exclusion? What is the time factor of when the offender or subject shows up on the LEIE list? Or are the various State Medicaid lists timelier? Not all states have Medicaid sanctions lists but the number has grown to 37 states with the recent addition of Iowa and Georgia this year.

Let’s take for example the case of CNA Kenisha Abeene. Her name showed up on the Nevada List of Sanctioned Excluded Providers in early 2014. Her name did not appear on OIG until January of the following year.

As a matter of process, TyphoonDATA pulls press releases from various Law Enforcement sites, both state and federal to gauge how fast the issues get across the spectrum of reporting entities which include Federal sources like OIG, DEA Disbarment, SAM.gov and state exclusion sites like https://dch.georgia.gov/georgia-oig-exclusions-list. Also the issues might initially surface in Licensing repositories like Department of Professional Licensing or DOPL (pronounced “Dop-Pull”) or specific board sites. Unfortunately, the states are not uniform in the approach to posting and size does matter with regards to provider type licenses. There are more Doctors and Nurses in this country so often those boards have daily updates.

For example, in the case of Physician Cyrus Sajadi, Dr. Sajadi was charged in 2012 and his name was all over the DOJ and other news sites. But, there was no action granted until 2015. Meaning his license stayed clear and without action for three years, making it possible for him to practice when he was known to have committed fraud. Leaving any organization that hadn’t known of his fraud opens them up to potential risk. For three years, his name did not pop up on the OIG or any state exclusion site. Knowing as much about your employees or potential employees as possible will cut away at your exposure to fraud or potential fines.

Moving from state to state also presents challenges. Doing a Social Security (SSN) trace often reveals multiple states the subject has lived, worked or studied. Name changes, especially in marital status, are also a driving issue. The exclusion is a post that is current at the time of posting and personal identifying information or Pii is needed to capture the action or exclusion. Often the board action is “thin file” or lacking identifiers so Sherlock Holmes will be needed to crack the case.

And last but not least this is not a one and done issue. Continuous monitoring not periodic batching is recommended. The on-going update process of data should be at a minimum monthly and some sites (Medi–CAL) have some provider types where daily updates are done.

Here are examples of delayed reporting:

INDIVIDUAL

PROVIDER TYPE

DATE OF BOARD ACTION

DATE OF APPEARANCE IN THE OIG LEIE

H, AMBER DAWN

Pharmacy Technician

10/25/2013

1/20/2015

B, BENJAMIN

CNA

12/22/2014

5/20/2015

P, THOMAS A

Pharmacy Technician

11/22/2013

1/20/2015

A, DAVID

LPN

5/15/2006

8/20/2006

A, KENISHA

CNA

3/27/2014

1/20/2015

 

Multi-State Licenses and Board Actions

I recently read an article on ProPublica (Read article here) about nurses who skip from state to state after receiving disciplinary actions. This has been and continues to be a huge weakness in the compliance industry.

When Craig Peske was fired from his nursing position in his home state in Wisconsin, and subsequently received an action against his license as well as six felony counts of narcotic possession, he used his “multi-state license” to get a job as a traveling nurse in North Carolina.

His license in North Carolina didn’t have an action against it, it was active and clear. It even surprised him when he checked on it. But, because his license was active, he had the ability to work as a nurse in North Carolina.

His license being clear in North Carolina could have been due to a lag time in getting the discipline on his record. Or because it’s possible that even with a multi-state license, the boards of separate states don’t communicate.

While I’m sure the hospital in North Carolina did their due diligence in searching his North Carolina license to confirm he was active. I believe they probably also searched for him in SAM and OIG to confirm he had no federal actions against him. What was missed, though, was that they clearly didn’t check into his Wisconsin license. The reason for this could range from Craig Peske not releasing the information that he did in fact have a license in another state. Or that their only requirement for employment is to have a free and clear license in the state of the employment.

There are many reasons why licenses for a practitioner can and will stay active when the practitioner shouldn’t be working in the healthcare industry anymore. Employing a nurse that has stolen painkillers at another facility creates a weak spot in your facility. It can open your facility up to being sanctioned or fined. It can put your patients in jeopardy as well.

And, although, most employers ask for every practitioner to disclose their actions, organizations can’t always trust employees to do so. As healthcare organizations, we need to gather as much knowledge about our practitioners as we can to protect our patients and our organization from fraud. I believe we owe this to the people out there trusting us to provide them with quality medical care.

That’s why TyphoonDATA’s product is so invaluable. With each new employee that is hired, you can search TyphoonDATA’s comprehensive database and see if there has been an action against them from a multitude of different sources. Or you can select one of our monitoring products, so with each refresh of the data, your employees are searched against the database. If a new record that matches your employee is found, you will be notified and TyphoonDATA does a verification to confirm or deny whether or not your employee is free and clear. It gives facilities and organizations just a little more comfort in knowing their employees are sanction free.

TyphoonDATA has packages that range from Basic Exclusion (searches against the OIG database) to Standard Plus (Searches against our entire database, including board actions, federal and state exclusions, and medicare opt-outs) to Premium Exclusion searches (Includes everything in Standard Plus, with a license check as well, to guarantee that their license is active and clear). All of our products are available as just a stand alone search, or with verification, or as a monitoring product.

Take a look at our products here.

Top 5 reasons why providers make the OIG Exclusion List

It is a common assumption that the majority of providers on the OIG List of Excluded Individuals/Entities (LEIE) arrived there by defrauding the Medicare/Medicaid systems. It turns out that program related crimes are the second most common reason for exclusion. The most common reason why providers are excluded is due to license revocation or suspension. Below are the top 5 exclusion types and their descriptions:

OIG_breakdown

Drilling down on why a given provider’s license was revoked or suspended is not always easy. The reasons for these revocations and suspensions are many. Often times, the notes or minutes coming from the state licensing board do not specify a reason as the relinquishment may have been voluntary. Additional digging is often required to get the full picture.

Let’s look at an example:

Malissa Bender, was recently excluded on the OIG List. She was excluded because the Florida Board of Pharmacy granted a “Voluntary Relinquishment of License” tendered by the provider in October, 2013. Additional internet research reveals that Bender was arrested in July 2013, for stealing schedule II and III drugs from the Pharmacy where she worked. (see story)

With over 25,000 providers excluded for type 1128b4 you can see how tedious case-by-case research can become to get to the bottom of each exclusion. Fortunately, in most cases, simply knowing that the provider’s license is suspended or revoked should be enough for most employers to take action. In some cases, the reason for revocation or suspension will not be due to criminal action, or any other reason known to the employer. This fact emphasizes the need for employers to monitor an employee’s license and exclusion status.

TyphoonData offers solutions for license and exclusion monitoring.

If you would like to discuss our thoughts and solutions, give us a call at 800-780-5901.