Significant Recent Trends in Exclusion Case Settlements

By Catalina Jandorf

Catalina photo

The Office of the Inspector General (OIG) has recently entered into a number of exclusion case settlements tied to skilled nursing facilities and hospitals.  Additionally, there have been several recent investigations targeted towards physician practices.  A rising number of these cases with sizable settlement recoveries highlight an emerging trend to be on the lookout for.

 

Recent Exclusion Case Settlements

OIG photo 1There appears to be a growing number of skilled nursing facilities and hospitals being implicated in connection with employing excluded individuals.  In November 2016, a New York rehabilitation center entered into a $205,089 settlement agreement with OIG.  It was alleged that the facility employed an individual who was excluded from participating in any Federal health care program. OIG’s investigation revealed that the excluded individual was a licensed practical nurse, who provided items or services to the center’s patients that were billed to Federal health care programs.

Similarly in the same month, another New York rehabilitation center entered into a $110,223 settlement agreement with OIG.  The investigation revealed that one excluded individual was a registered nurse supervisor and another was a licensed practical nurse, both having provided items or services to the facility’s patients that were billed to Federal health care programs.

Also in November 2016, a California hospital agreed to pay $190,087 for allegedly violating the Civil Monetary Penalties Law following a Self-Disclosure Protocol (SDP) settlement.  In July 2016, a North Carolina and a California hospital agreed to pay $475,220 and $207,698 respectively for allegedly violating the Civil Monetary Penalties Law.  In each of these cases, OIG alleged that the hospitals employed an individual that they knew or should have known was excluded from participation in Federal health care programs.

Another trend in exclusion liability involves targeting physician practices and individual physicians.  A recent case implicated a medical group practice and a physician in Texas that agreed to pay $435,481 in Civil Monetary Penalties (CMPs) after they self-disclosed conduct to OIG.  OIG alleged that the practice employed an individual that they knew or should have known was excluded from participation in Federal health care programs.

False Claims Act Liability

In addition to facing exclusion sanctions and CMPs, an individual or entity may also be found to be liable under the False Claims Act (FCA).  Another physician exclusion case settlement from September 2016 involved a Puerto Rican physician who agreed to be banned from participation in all Federal health care programs for a period of five years in connection with the resolution of FCA liability.  OIG alleged that the physician submitted or caused to be submitted false claims under Medicare when he furnished health care services to Medicare beneficiaries in a hospital emergency department while he was excluded from participating in Federal health care programs.

In another recent case, a Pennsylvania chiropractor agreed to be excluded from participating in Federal health care programs for a period of twenty-five years in connection with FCA liability.  OIG alleged that the chiropractor knowingly submitted or caused to be submitted false or fraudulent claims to Medicare for services rendered as a de facto executive and administrator of a chiropractic center even though he was excluded from participating in Federal health care programs.

Conclusion

If this steady trend of skilled nursing facilities and hospitals facing exclusion liability is any indication, the OIG will continue to aggressively enforce screening requirements and impose strict sanctions.  In addition to the being found liable for CMPs, False Claims Act liability may come into play if an excluded individual submits false claims under Medicare.  If found to be in violation of the FCA, the individual or entity will be required to pay a mandatory penalty, which is currently in the range of $5,500 and $11,000 for each false claim submitted, and be liable for treble damages.

With the increase of OIG exclusion case settlements and larger settlement amounts, screening employees, vendors and contractors against the OIG’s List of Excluded Individuals and Entities (LEIE), the GSA’s System for Award Management (SAM), and all 38 state lists every month is critical.  To eliminate the risk of having to self-disclose a possible exclusion violation or undergo an OIG investigation, contact the Exclusion Experts at 1-800-294-0952 or online for a free consultation.