Download Exclusion Monitoring White Paper Deck Final May 2015

Exclusion and License Screening –
Not an Option
April 28, 2015
OIG Guidelines Clarification
(May 2013)
• Providers, contractors, and employees need to be checked prior to
employment or contracting, then monthly for:
– Exclusions
– Licenses (if applicable)
• If excluded from any federal agency program, then party is excluded
from ALL government health care programs (Medicare, Medicaid,
CHIP, Tricare, Veterans programs)
• Who is “accountable”? Anyone “who knows, or should know” of
the exclusion, yet allows the excluded person/entity to deliver
services and get paid with any Government monies
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Who Should be
Screened for Exclusions?
• Per OIG: any employee (including leadership), practitioner,
contractor, or entity paid with money obtained from a Federal
health care program, either directly or indirectly, or in whole or in
part
• Exception: “if payment is from funds separated from any
Government monies” – virtually no health care organizations have
segregated accounting systems and therefore do not qualify for
exception
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Potential Consequences of Employing
an Excluded Person/Entity
• Payments stopped or suspended
• Civil Monetary Penalties (CMPs)
– $10,000 per each claimed product and service, plus treble damages
(3 times the cost of the product and service)
– One excluded provider quickly results into $-millions!
• “False claims” liability
• Debarment
• Incarceration
Similar potential consequences apply for employing an unlicensed
person/entity; though CMPs vary based on the severity of the situation
(unlicensed, revoked/suspended license…), they can be in the same
range as for employing an excluded person/entity.
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Primary Sources to Check Exclusions
OIG recommends that screening be performed through the List of
Excluded Individuals and Entities (LEIE):
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•
•
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Maintained by OIG
Updated monthly
Provides more details about basis for exclusion than GSA’s SAM
OIG staff can respond to questions and requests for verifications
Best practice is to check LEIE, System for Award Management (SAM),
and all Medicaid exclusion lists from currently-reporting states (to
mitigate timing of reporting from State to Federal)
(OIG Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health
Care Programs, May 8, 2013; http://oig.hhs.gov/exclusions/files/sab-05092013.pdf)
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Checking on Licensure
OIG:
“We require that Medicare contractors review State licensure board
data on a monthly basis to determine if providers and suppliers remain
in compliance with State licensure requirements.”
(Federal Register, Vol. 76, No. 22, February 2, 2011, Pp. 5865-5866.)
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What is FACIS?
• Sanctions, Exclusions, Debarments, and Disciplinary Actions
• All
– Providers, Persons and Entities
– All Provider Types
– All Reporting Jurisdictions
• Current and Historical
• Primary Source Data only
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Level 1M
• Includes 139 federal sources, 120 state sources
– Federal level data plus state Medicaid sanctions (35 states), 42
HEAT sources, 51 AG Notice and Release sources and state level
procurement/contractor debarment sources
– OIG, SAM, DEA, FDA, PHS, ORI, TRICARE and OFAC‐SDN data
(federal only) and Medicare Opt-Out
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Level 3
• All sources included in FACIS 1M, plus
– Data available from all publishing jurisdictions in the United
States from all disciplinary and licensing boards including all
professionals within those jurisdictions
– Includes the District of Columbia
– Includes all provider types (not just MDs and DOs)
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