In September 2021, the Department of Justice (DOJ) announced its latest crackdown on healthcare fraud. Criminal charges were brought against 138 individuals, “including 42 doctors, nurses, and other licensed medical professionals…for their alleged participation in various health care fraud schemes that resulted in approximately $1.4 billion in alleged losses.” $1.1 billion of these losses were a result of fraud committed while using telemedicine practices.

This latest fraud enforcement action, along with similar action taken September 2020 (which resulted in uncovering over six billion in alleged losses), signifies that the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) will continue its fight against fraud and abuse as telemedicine continues to expand during the pandemic.

Employers should remain vigilant in their exclusion screening practices to avoid not only risk to their organization, but also potential civil monetary penalties of up to $10,000 per instance.

What is an exclusion?

An exclusion is when an individual or entity has been excluded from federally funded healthcare programs. There are two types of exclusions: mandatory and permissive.

1. Mandatory exclusions carry a minimum of five years. They are handed down for criminal/felony convictions related to Medicare or Medicaid services, patient neglect or abuse, healthcare fraud, controlled substances, and more.
2. Permissive exclusions carry varying exclusion lengths. They are handed down for misdemeanor convictions in healthcare fraud or controlled substances, obstruction of an investigation, non-healthcare fraud, and other reasons.

What is exclusion screening?

Exclusion screening is the practice of ensuring that a candidate or current employee is not currently an excluded individual on the OIG’s List of Excluded Individuals/Entities (LEIE), as well as other exclusion lists, including:

• SAM: System for Award Management, including:
  • Central Contractor Registry (CCR)
  • Federal Agency Registration (Fedreg)
  • Online Representations and Certifications Application
  • Excluded Parties List System (EPLS)
    • Includes OIG Data
       
• OFAC (Office of Foreign Assets Control)
  • Sometimes known as the “terrorist list”
     
• FDA (Food & Drug Administration) Disqualification and Debarment List
  • For those who are research facilities or conduct clinical trials
    ​
• State Medicaid Exclusion Lists
  • 42 states currently publish their lists, all which need to be checked regularly, as entries do not always show up on the OIG list

What are exclusion screening best practices?

Healthcare HR departments should regularly screen all candidates, new hires, and current employees for HHS-OIG exclusions. The following are some best practices to consider while conducting these screens.

1. Work with legal counsel to determine databases to screen. Your company’s requirements may differ state-to-state, and from one regulator to another.

2. Know your sources. Familiarize yourself with your required databases, the information they provide, and how to have the best chance at getting a name match.

3. Search before hiring, and periodically afterward. The OIG updates the LEIE monthly, and recommends that you screen monthly, as well as state Medicaids.

4. Explore name variations. Try searching for other variations of names, nicknames, and the first few letters of the first and last name..

5. Review name matches thoroughly. When possible, use other identifiers to positively identify individuals, such as social security numbers, dates of birth, or even addresses. It can be helpful to have a dedicated employee or team who specializes in sanction monitoring.

6. Document. If audited, you want to be able to show that you did everything possible in order to not hire someone who’s excluded; or, if you find yourself needing to terminate an employee, you may need to defend that action. We recommend taking screenshots, saving time stamps, and storing documents in a secure space.

7. Consult with legal counsel. If you hire someone who is sanctioned, terminated, or debarred, we suggest you seek legal counsel immediately and follow reporting guidelines. You may also want to use the OIG Self-Disclosure Protocol, a program in which you can self-report potential violations.

8. Consider using an exclusion screening solution to assist you. A comprehensive exclusion screening solution can streamline this process for your organization by identifying individuals who have been excluded, terminated, sanctioned, or debarred from the various federal and state programs. Using a full-service exclusion solution such as PreCheck’s SanctionCheck® can help your organization ensure thorough, accurate screening and reporting results.

Following these best practices will help protect your organization from liability, ensure compliance with federal guidelines, and avoid costly penalties. If you would like more information on how PreCheck can assist with your exclusion screening program, contact us today.