I. Florida’s State Exclusion. Excluded Providers Costs OIG Over 2.7 Million
The Office of the Inspector General (OIG) recently released a study on a subset of Florida’s Medicaid payments for pharmaceutical items. The study showed that in 2009 and 2010 the State agency made $180,000 in payments for pharmaceutical items prescribed by excluded providers. OIG, comparing this number to the total number of pharmacy payments, concluded that the State agency may have paid up to $2.7 million for items that excluded providers had prescribed.
OIG concluded that these over-payments occurred because the State agency did not have proper policies in place to conduct prepayment review. Specifically, the agency had not established sufficient prepayment controls to ensure that valid provider IDs were on every pharmacy claim, and that the prescribing provider identification numbers were valid before making payments.
II. Monthly Exclusion Screening Is Essential to Maintaining Effective Compliance Programs
Furthermore, the State agency was only conducting periodic searches of the LEIE and the GSA-SAM, which are maintained by OIG and CMS, respectively. This serves as just another reminder to providers that exclusion searches, in order to be effective, must be conducted monthly and must include searches of the LEIE, the GSA-SAM, and all 41 state Medicaid lists. Failure to search every list creates a hole in your screening process and allows excluded individuals to continue billing to the Federal health care programs.
Florida has since created its own suspended provider list like a majority of the states. In addition to building this new system, it also refunded the Federal health care programs in the amount of $99,568. That expense could have been avoided with thorough monthly exclusion checks.
All providers must conduct monthly exclusion screening on the LEIE, GSA-SAM, and all 41 state Medicaid lists. OIG is aggressively cracking down on providers who employ excluded individuals and will impose Civil Monetary Penalties (CMPs) of up to $10,000 for each item or service billed to the Federal health care programs that was provided directly or indirectly by an excluded individual.
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Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. Feel free to contact us at 1-800-294-0952 or online for a free consultation.