Sanction Screening: Federal and State Terminations

Senior Director of Marketing

In May 2013, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) issued a Special Advisory Bulletin concerning excluded individuals and entities. Within the advisory bulletin, the first in over a decade, the OIG alerted organizations receiving federal funding from Medicare that it is highly recommended that they monitor the OIG’s List of Excluded Individuals and Entities (LEIE) on a monthly basis in order to minimize their liability from civil monetary penalties. If your organization has a monthly sanction screening program in place, you are among those following the industry’s emerging best practices. But is monitoring the OIG’s exclusion list enough to safeguard your healthcare organization and patients from problem physicians? Senator Charles Grassley, R-Iowa, begs to differ.

Medicaid and Medicare: The Disconnect

According to an article by ProPublica, Sen. Grassley sent letters to all 50 states in June 2013 regarding an issue concerning how states sanction doctors in their state health programs. Grassley questioned whether states alert the federal government when they remove a physician from the State’s Medicaid program. The senator cited specific examples from a May 2013 ProPublica report that examined 2007-2010 data from Medicare Part D. The report showed that, in several cases, “Medicare failed to act against providers who have been suspended or disciplined by other regulatory authorities.” The data illustrate cases like that of Enrique Casuso, a Miami psychiatrist who was excluded from Florida’s Medicaid network in 2005 for lacking “awareness or oversight of the medication prescribed.” Nevertheless, Dr. Casuso has continued prescribing drugs under Medicare’s Part D program.

According to the data, exclusion from one program does not warrant exclusion from the other. Medicaid is mutually funded by the states and the federal government, but is run by the states. Medicare, however, is run by the federal government. Because of the current disconnect between both programs, seniors and disabled patients primarily served by the Medicare program remain vulnerable to individuals sanctioned by state Medicaid networks.

Medicaid Terminations Without Cause

Physicians can be excluded from a state’s Medicaid program for several reasons. Terminations with cause, although legally burdensome, allow Medicare to use them against doctors. Unfortunately, the same cannot be said about terminations without cause. Although this type of termination allows states to take action quickly, physicians removed without cause from Medicaid have little repercussions. They still have a valid medical license and can continue to practice and bill Medicare or any other insurance plan willing to do business with them.

When it comes to mitigating risk for your healthcare organization and patients, monitoring a federal exclusion list such as the OIG LEIE does not protect your organization from state level Medicaid sanctions. Consequently, considering a more robust sanction screening program that also encompasses State Medicaid exclusion lists would be worthwhile to further protect your organization’s liability. Exclusion and sanction screening services that monitor State Medicaid exclusion lists, like PreCheck’s SanctionCheck, can help automate this process for your organization while saving internal resources. 

Photo credit: mariachily / Flickr