Tag: OIG

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).

How does the OIG determine who to Exclude

The OIG (Office of Inspector General) has updated their “Criteria for implementing section 1128(b)(7) exclusion authority.”

Here is a link to the OIG write up about the new standards. https://oig.hhs.gov/exclusions/files/1128b7exclusion-criteria.pdf

 

The OIG has a mission “to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.”  To fulfil this mission the OIG creates resources to help the health care industry comply with the Nation’s Fraud laws. They also work to educate the public, to protect them from fraud, and to have the public report suspicious activities. The Office of Counsel to the Inspector General (OCIG) is responsible for imposing program exclusions and civil monetary penalties (CMP) on health care providers. The excluded health care providers are included on a list known as the List of Excluded Individuals/Entities (LEIE). This article will summarize the current method the OIG uses in determining the action taken against an individual or entity.  

 

Risk Spectrum

The OIG will be using a scale to determine the action taken, ranging from Exclusion to imposing Integrity Obligations to Release. There are a number of factors included in the risk assessment, which then determine the course of action the OIG will take. The categories included in this evaluation are; The Nature and Circumstance of the Conduct, Conduct During the Investigation, Significant Ameliorative Efforts, and History of Compliance.

 

Factors applied to determine the action taken

These Factors have an impact on the risk assessment, they indicate a higher risk, a lower risk, or can be neutral in determining what action will be taken by the OIG. Here is a quick summary  

  1. Nature and Circumstance of Conduct
    1. If the conduct had an adverse impact on Individuals
    2. Financial loss- the greater the amount of loss or intended loss to the Federal healthcare programs the greater the risk assessment.
    3. Conduct that occurs as part of a pattern, or over a period of time, or is continual or repeated indicates a higher risk
    4. Conduct that is currently ongoing or was continued until the Government began an investigation leads to a higher risk
    5. A lack of criminal sanctions has no impact on the level of risk
    6. Leadership Role- if the individual organized, led or planned the unlawful activity
    7. History of Prior Fraudulent Conduct, including prior judgements or convictions, refusal to enter into a Corporate Integrity Agreement (CIA), having a prior CIA, and failing to cooperate with OIG while under a CIA all indicate higher risk levels
  2. Conduct during Investigation
    1. Overall response to the investigation
      1. Did the individual obstruct or impede the investigation or attempt to do so?
      2. Was anything done to conceal the conduct from the government
      3. The inability for a person to engage in the conduct again for whatever reason has no effect on the risk assessment
      4. While a prompt response to the subpoena has no effect, failure to comply within a reasonable time frame would result in a higher risk assessment.
    2. Internal Investigation
      1. If an internal investigation began prior to the individual or entity learning about the Government’s investigation, and any information gained as a result is shared with the government, risk will be lower.
      2. If the person self-disclosed the conduct prior to the Government’s investigation, this would also result in a lower risk assessment.
    3. Cooperation
      1. If the person cooperates with the Government the risk assessment is lower.
      2. If through the person’s cooperation a criminal, civil, or administrative action is taken against an individual or entity, then risk assessment is lower.
    4. Resolution
      1. Adverse Licensure action increases the risk
      2. A criminal resolution including either a conviction, a Deferred Prosecution Agreement, or a Non-Prosecution Agreement. Any of these actions will increase risk which varies depending on the type of criminal action taken
  3. Significant Ameliorative Efforts
    1. Significant changes in the entity
      1. The entity taking appropriate action against the individual lowers risk.
      2. If the entity has dedicated more resources to insure compliance this will also lower the risk.
      3. If after the conduct has stopped, the entity has been sold to a non-affiliated, independent third party that has a history of compliant participation in Federal healthcare programs, the risk will be lower
      4. If there has been additional training, or a mentor assigned or other mitigating steps have been taken that will also lower the risk assessment.
  4. History of Compliance
    1. If the person has a history of appropriate timely self-disclosure made in good faith the risk will be lower
    2. Having a compliance program in place has no impact on risk level, but not having a compliance program in place that incorporates the U.S. Sentencing Commission Guidelines Manual’s seven elements of an effective compliance program will increase the risk.

 

Summary

This new criteria helps clarify the process for how a health care provider can find themselves excluded by the OIG. If an individual or entity is on the LEIE, then “no payment will be made by any Federal health care program (ie; medicare or medicaid) for items or services furnished, ordered, or prescribed by the excluded individual in any capacity.” The OIG can impose penalties on entities and individuals who bill the Federal government for services while excluded by the OIG. These Civil Monetary Penalties (CMP) can be up to $10,000.00 per occurrence plus treble damages.

At Typhoon Data one of our services is to verify that providers are not on the LEIE. We offer a variety of services to help maintain compliance.

 

If you would like to discuss our solutions, feel free to contact me, David Rees at (800) 780-5901 Ext 705 or email drees@typhoondata.com.

Risk: It’s All About Time!

usa-flag-map

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.

SAM.gov Exclusions – What Are They, and Where do They Come From?

SAM.gov publishes an exclusion file used by many organizations for screening and/or compliance purposes. This exclusion file replaces the former EPLS files as of November, 2012. The SAM exclusion file receives regular updates and contains the collective exclusion reporting of over 80 different federal agencies totaling to approximately 130,000 exclusion records. An exclusion record from SAM.gov indicates that the individual or organization listed is disqualified from receiving any federal government contracts. S.A.M. stands for System for Award Management. This system is used for any party seeking to be awarded a federal government contract and become a federal vendor or supplier.

Let’s take a look at the break-down of the SAM.gov exclusions to see where most of the information comes from. As seen in the chart below, almost 1/2 of the SAM.gov exclusion records come from the Department of Health and Human Services’ OIG LEIE exclusion list. The top 6 contributors to the SAM.gov file makeup over 90% of its total records. The chart below only shows the top 27 federal agencies that report to SAM, there are many more which have made small record contributions.

Each agency that reports to the SAM exclusion system is responsible for the accuracy of its records and the information they contain. Exclusions records have a “type” and a “termination date”. The types are generally “Prohibition/Restriction” or “Ineligible”. In some cases the type may indicate “Proceedings Pending” or “Proceedings Completed”. These types give a little insight into the status of the investigation resulting in exclusion. The termination date in the record indicates the shelf-life of the exclusion. In some cases, a future date is present. This means that once that date is reached, the party on record is no longer excluded. In many cases, the word “Indefinite” is seen in the termination date. An indefinite exclusion never expires and can only be removed at the digression of the reporting agency. If specific conditions or criteria are met, the excluding agency may remove the exclusion. SAM does not publish a reinstatement list, non-excluded parties are simply removed from the updated file. Some reporting agencies (such as the OIG) do maintain their own reinstatement lists.

 

SAM Pie3

TyphoonDATA offers data and compliance solutions that include the SAM.gov exclusions file and much more.

To speak with TyphoonDATA directly, please contact:

Richard Rupert, VP Compliance Solutions
Office: 800.780.5901 extension 705
rrupert@typhoondata.com

Slipping Through the Cracks in the Process

More and more public watchdog groups, press and user groups are finding holes in the system that may be of concern to those who are hiring or credentialing medical providers.  The article dated June 30, 2014 from NPR demonstrates the complexities and timing issues.  Some providers are able to circumvent the billing process and continue to receive payment for years after being acted upon by the various state medical boards. http://www.npr.org/blogs/health/2014/06/20/323889329/sanctions-common-against-doctors-with-odd-medicare-billing?ft=1&f=1001

Credit Reporting Agencies focusing on hiring, compliance groups and credentialing organizations have the mission to surface issues beyond just the exclusion data repositories like the Office of the Inspector General (OIG) or one of the many Federal sites that track violators.  As you know, being excluded from the Federal Medicare process is only one element of the wider net that is needed to get all the data to make a hiring, risk or just plain due diligence decision.

The problem is often just timing.  A scenario might be a provider is arrested for a crime and adjudication begins.  Maybe a state medical board reviews the incident and takes action.  The various states may jump into action and exclude the provider from receiving Medicaid payments which is administered from the states even though the money comes primarily from the Federal tax dollars.  The license may be affected at the board level and it make take time to get into the exclusion process.  Hearings have to be set and conclusions reviewed.

It is the due process that takes time and we all appreciate the need for it.  But if you are a hiring entity or compliance group you may get caught in the cracks.  The key is to check the various Federal, State and board actions that will blanket the whole process.

It is possible to get an accurate, up to date picture and TyphoonDATA has a solution with will cast a wide net, verify the false positives and close the cracks into a simple to use click process.

If you would like to discuss, call us at 800.780.5901 or email us at RRupert@typhoondata.com or SSkyhawk@typhoondata.com .  We would love to help you with your mission.

 

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.