Healthcare Exclusion and Sanction Checking Best Practices for 2014

Earlier this year, we addressed some of the frequently asked questions concerning exclusion and sanction screening. This article focuses on the current recommended best practices for the healthcare industry, given the latest publicly available exclusion information, as well as recommendations and guidelines from regulatory agencies. Here’s what we recommend for every healthcare organization in order to minimize the level of risk when it comes to checking for exclusions and sanctions.

Determining Who Should Be Screened for Exclusions

This is a very valid question and it’s one that comes up quite frequently, especially when healthcare providers consider whether to screen for hospital volunteers and nursing students. If they are not receiving federal healthcare dollars, then the answer would be no. It’s highly recommended, however, that you screen volunteers and students for exclusions. The exception would be if you are a private organization and receive no federal healthcare dollars, then you would not be subject to Civil Monetary Penalties (CMPs).

At PreCheck, we also conduct student background checks as part of our suite of services and as recent as last month, we found that one of our client’s volunteers was excluded from a state Medicaid exclusion list. In some cases, it’s possible to be reinstated, but the fact of the matter is our client had a volunteer at their facility that was excluded from federal healthcare programs.

When determining who should be screened at your organization, keep in mind that it’s not just about who physically contacts patients. The latest guidance states that both direct and indirect patient contact matters. This is commonly misconstrued as just those who touch the patient, but it actually includes anyone that’s supplying goods or services.

Checking the State Medicaid Exclusion Lists

While the OIG’s LEIE is the main exclusion list you should be screening as part of your compliance program, it’s not enough and ignoring other public available exclusion lists could place a considerable amount of risk on your organization. At the time of this article, there are currently 34 State Medicaid Exclusion Lists and some of the names on these State Medicaid Exclusion Lists do not meet the criteria to be on the OIG’s LEIE. PPACA, Section 6501 requires States to terminate providers who have been terminated under another States Medicaid Program. The top reason to check the State Medicaid Exclusion Lists as part of your exclusion screening program is to check the latest publicly available information—based on our experience, it can take as long as two years before some state exclusions are added to the OIG LEIE database.

In 2013, for example, the OIG conducted an onsite review of the Texas Medicaid Fraud Control Unit and found that the Unit did not transmit all criminal conviction information to the OIG in a timely manner. In this study, the OIG recommended that the Texas Unit ensure that it transmits information about all convictions to them for exclusion within 30 days of sentencing. This is just one example of how states fail to provide timely information to the OIG concerning exclusions. Therefore, as a best practice, it is highly recommended that you check the state level exclusion lists in order to minimize the level of risk for your organization.

Screen for Exclusions on a Monthly Basis

Monthly exclusion screening has become the new standard for the industry. While the OIG issued a Special Advisory Bulletin in May 2013 in which it recommends checking the OIG LEIE on a monthly basis, this was not the first time a monthly screening frequency was suggested as a best practice. While we’ve certainly seen our clients moving towards a monthly screening schedule over the past few years, CMS made the monthly screening recommendation years earlier than the OIG’s Special Advisory Bulletin. In March 2011, CMS issued guidelines that suggested that providers search on a monthly basis. In June 2009, CMS also sent a letter to 50 State Medicaid Directors in which the agency suggested that they remind healthcare employers of their duty to search on a monthly basis. The monthly exclusion screening frequency, therefore, has been a recommended best practice from regulatory agencies for almost 5 years now.

Exclusion Screening Tips in a Nutshell

As discussed above, monthly exclusion screening is the new standard for the frequency of conducting sanction checks in the healthcare industry. It’s also important to know who owns more than 5% of entities that you engage with, as the OIG is also going after the owners of excluded entities. Make sure that you are also checking the GSA SAM (formerly the EPLS) and the 34 State Medicaid Exclusion Lists as part of your exclusion screening program in addition to the OIG LEIE. Finally, have a system in place to prepare for OIG audits. If you can easily demonstrate that you’ve been running monthly exclusion checks, then you can show that your organization has acted in good faith to screen against the latest publicly available information. For clients of our SanctionCheck exclusion screening service, for example, our web-based system keeps a record of every sanction check run indefinitely. If you outsource exclusion checks, make sure that you’ll have access to this information should you need it later in the event of an audit.