OIG Trumpets Exclusions, New Actions and Recoveries in its Semi-Annual Report to Congress

OIG report
I.  OIG Report

In the Office of the Inspector General’s (OIG) semiannual report to Congress, it claimed credit for excluding 2,297 individuals and entities from Medicare, Medicaid, and other Federal health care programs. The OIG also claimed credit for initiating 506 criminal and 267 civil actions. According to the OIG report, most of the exclusions resulted from convictions for crimes relating to Medicare or Medicaid, patient abuse or neglect, or license revocations. The civil and criminal actions were primarily initiated against “individuals or entities engaged in health-care related offenses.” In addition, the OIG told Congress that it was responsible for generating $1.26 billion in investigative receivables due to the Department of Health and Human Services.[1]

II.  Failure to Screen

The OIG also identified some of the cases that were felt to be important. Two of these cases involved exclusion related issues. In one case, the OIG imposed $15,000 in penalties against a company under a corporate integrity agreement for failing to timely screen employees and other “covered persons.” This is of particular interest to us because the penalty was not imposed for having an excluded employee. Instead, the penalty was imposed for failing to screen! This, again, demonstrates the interest and concerns of the OIG in exclusion issues.

III.  Mandatory Exclusion 

In the other case, a physician who had been excluded due to a conviction for a health care related offense, arranged an elaborate scheme to hide his involvement in a dermatology practice so that it could bill Medicare and Medicaid for services despite his excluded status. His scheme was eventually discovered, and he was tried by a jury. He was then convicted of health care fraud, bankruptcy fraud, identity theft, and the filing of false tax returns. Ultimately, he was sentenced to 8 years and 3 months of incarceration, ordered to pay $265,330 in restitution, and fined $2.6 million. 

IV.  Permissive Exclusion

Finally, the OIG report also states that the OIG continues to enforce the HEAL (Health Education Assistance Loan) Program. It further states that 20 individuals entered into settlement agreements, and $1.5 million was collected during the reporting period. We bring this up as a reminder that vigilance in this area is a necessity! There are any number of different ways for individuals and entities to be excluded from Medicare and Medicaid. Let the experts at Exclusion ScreeningSM help ensure your organization does not employ an excluded individual or entity.

Contact us for a free consultation at 1-800-294-0952 or fill out the form below.



OIG Exclusion

Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article.


[1] U.S. Dept. of Health & Human Services Office of Inspector General Semiannual Report to Congress, at 26.

Who Should Be on my OIG Exclusion Screening List?

oig exclusion screening list
I. Federal and State Agencies Conducting Audits

As many health care providers and suppliers have painfully learned over the last year, federal and state law enforcement agencies, along with many of the contractors with whom they work, are actively conducting audits of Medicare and Medicaid claims submitted to the government for coverage and payment.

One of the least understood mandatory obligations applicable to virtually every health care provider and supplier who accepts Medicare or Medicaid is the requirement that all participating providers are REQUIRED to screen more than just their staff. Instead, they must also screen contractors, vendors, and agents to ensure that they and their employees have not been excluded from participation in federal and state health care programs. The fact that these individuals and entities must be screened through literally dozens of federal and state exclusion databases further complicates this mandate. 

II. Broad Scope of OIG Exclusion Action

Importantly, the scope of an exclusion action is extremely broad. The Department of Health and Human Services, Office of Inspector General (HHS-OIG) has taken the position that if a vendor, contractor or supplier of administrative, management or support services has been excluded from participating in the Medicare or Medicaid programs, they are effectively barred from working with most health care provider and supplier entities. As HHS-OIG writes:

Excluded persons are prohibited from furnishing administrative and management services that are payable by the Federal health care programs. This prohibition applies even if the administrative and management services are not separately billable. For example, an excluded individual may not serve in an executive or leadership role (e.g., chief executive officer, chief financial officer, general counsel, director of health information management, director of human resources, physician practice office manager, etc.) at a provider that furnishes items or services payable by Federal health care programs. Also, an excluded individual may not provide other types of administrative and management services, such as health information technology services and support, strategic planning, billing and accounting, staff training, and human resources, unless wholly unrelated to Federal health care programs.”1

At Exclusion ScreeningSM, we realize that compiling a list of all employees, vendors and contractors can be a daunting task. That’s why we help our customers evaluate and determine exactly who needs to be included during their monthly Exclusion Screening. 

III.  Creating Your OIG Exclusion Screening List

A partial listing of the parties you are required by law to screen include:

All employees and Staff: To properly screen you should be sure to examine (or submit this information to us so we can conduct the screens for you):

1.  SSN.

2.  Maiden names.

3.  Any former names.

4.  Birthdate.

Vendors, Contractors and Agents: You MUST screen vendors that provide items or services directly OR indirectly that are payable in whole or in part by the Federal health care programs2

Some potential vendors that must be included on your list:

1.  Ambulance and other Transportation Service Providers.

2.  Volunteers.

3.  IT Solution Providers.

4.  Security Technicians.

5.  Medical Equipment Managers.

6.  Food Service Workers.

7.  Lab Technicians.

8.  Pharmacists.

9.  Nurses and other Individuals Provided by Staffing Agencies.

10. Physician Groups that Provide Emergency Room Coverage.

11. Billing or Coding Contractors.

12. Directors.

13. Administrators.

14. Managers.

IV.  Contractors and Vendors

When it comes to contractors and vendors, HHS-OIG offers some interesting guidance in its 2013 Special Advisory. The OIG gives providers two options: (1) providers themselves may screen their contractors’ or vendors’ employees;3 or (2) a provider may rely on a contractor’s or vendor’s certification that the contractor or vendor is conducting screening of its own employees and contractors. Note that HHS-OIG recommends that the provider validate that the contractor is conducting such screening on behalf of the provider. One way providers can validate this information is by requesting and maintaining screening documentation from the contractor.4

V.  Screen for Exclusions: Avoid CMPs!

Screening this list can seem like a daunting task, but not doing so can create a world of hurt. The phrase “leave no stone unturned” couldn’t be more appropriate in this case. An effective compliance policy demands that providers employ comprehensive screening practices. Although the process may seem arduous, the risks providers face, if they do not screen, are dire. The Civil Monetary Penalty (CMP) for any item or service provided by an excluded individual or entity is up to $10,000. On top of CMPs, the providers may be required to pay up to three times the total amount of claims submitted to Medicare.  

Considering the hefty liabilities tacked on for merely employing even one excluded individual, it’s easy to see that making the effort to properly screen for exclusions pays for itself. If you’re worried that your organization isn’t screening the right individuals and entities, the exclusion experts at Exclusion ScreeningSM are happy to help you create your employee and vendor list. Feel free to contact us at 1-800-294-0952 or fill out the form below.

 



 

Ashley Hudson, oig exclusion screening list

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.


[1]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15

[2]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15

[3]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 15-16

[4]  Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs p. 16

Must Haves for a Proper Exclusion Screening Process

exclusion screening process

Must Haves for a Proper Exclusion Screening Process


At Exclusion Screening, LLCSM, we know the ins-and-outs of the exclusion screening process. In our opinion, an effective screening process requires some mandatory tools. To ensure that there are no holes in your screening process make sure you have:

1 – A List of Employees and Vendors

All providers need a complete list of employees and vendors. Your Exclusion Experts here at Exclusion Screening, LLCSM will ensure that you aren’t missing any vendor that may present a liability. We know that it may be difficult to think of every possible contractor that directly or indirectly furnishes an item or service that is payable by the Federal health care programs. That’s why we guide our clients through the list making process.

If you choose to do your own screening, you must ensure that you have the following pieces of information for all employees and contractors: full name, maiden name, date of birth, address and Social Security Number.

2 – Access to Exclusion Lists

Providers who perform their own screening will need to have the ability to access the online state and federal databases. At a minimum, providers should check their employee and vendor lists against the OIG-LEIE, GSA-SAM, and the 41 state Medicaid Exclusion Lists.

3 – Time and Ability for Exclusion Screening

Finding time for monthly checks may be difficult, but it is critical. Employing one excluded person can cost a provider tens of thousands of dollars.

Proper exclusion screening is going to take a decent chunk of one employee’s time. If you do not have a staff member to completely commit to screening then consider outsourcing this job to a professional exclusion screening company.

5 – The Budget

Conducting monthly exclusion screenings will cost money regardless of whether you choose to screen in house or contract the job out. While it may seem like a hefty expense, if OIG discovers that you employed or contracted with an excluded individual or entity, you will be liable to pay Civil Monetary Penalties of up to $10,000 per item claimed and assessments of up to three times the amount of each item claimed. As Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.”

Ensuring that your exclusion screening process contains these five elements will keep your practice compliant and off of OIG’s radar. If dedicating your resources and time to effective exclusion screening seems to overextend your practice consider outsourcing the job to Exclusion Screening, LLCSM.  Contact us today at 1-800-294-0952 or fill out the form below.



 

Ashley Hudson

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.

How to Apply for Reinstatement

OIG Exclusion Reinstatement

I. The OIG Exclusion Reinstatement Process

Most exclusions are imposed for a definite time period. The question for an excluded individual or entity is: What happens at the end of the exclusion period?

   The answer is that the excluded individual or entity must apply for reinstatement. The U.S. Department of Health and Human Services (HHS) will NOT automatically reinstate the person or entity at the end of the exclusion period.

An excluded provider may apply for reinstatement 90 days before the date specified on his, her, or its exclusion notice letter. To apply for reinstatement the excluded individual or entity must send a written request to:

HHS, OIG, OI
Attn: Exclusions
P.O. Box 23871
Washington, DC 20026
(202) 691-2298 (Fax)

  The Office of the Inspector General (OIG) will send the provider Statement and Authorization forms to complete, notarize, and return. OIG will review these forms and will send the provider a written notification of its final decision. This process may take 120 days or longer to complete.

II. Denial of OIG Exclusion Reinstatement

If the application for reinstatement is denied, the excluded individual or entity may submit evidence and a written argument against the continued exclusion; a written request to present written evidence and oral argument to an OIG official; or documentary evidence and a written request to present oral argument.[1] The evidence, written argument, or written request for a hearing must be submitted 30 days after the provider receives the written notice of OIG’s final decision.[2]

After reviewing the materials (or after the 30-day period, if no materials are submitted), OIG will send the provider written notice either confirming the denial or approving the request for reinstatement.[3] If OIG confirms its decision to deny reinstatement, the decision will not be subject to administrative or judicial review and the provider must wait at least one year to submit another request for reinstatement.[4]

Read more on OIG Exclusion 

 OIG Exclusion Reinstatement 

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.


 [1] 42 C.F.R. 1001.3004 (2014).

[2] 42 C.F.R. 1001.3004.

[3] 42 C.F.R. 1001.3004.

[4] 42 C.F.R. 1001.3004.

The Administrative Process of Imposing an OIG Exclusion

Imposing OIG Exclusions

I.  Mandatory OIG Exclusions

When the Office of Inspector General (OIG) considers imposing a mandatory exclusion, it sends the individual or entity a Notice of Intent to Exclude.[1] The Notice includes the reason for the proposed exclusion and the possible effect of an exclusion. It also gives the individual or entity 30 days to respond in writing with information and evidence that he or she wants the OIG to consider in making its final decision.

The OIG will almost always decide to impose a mandatory exclusion. The individual or entity is then sent a Notice of Exclusion that includes his or her appeal rights. The exclusion goes into effect 20 days after the Notice of Exclusion is mailed and notice to the public is provided on the OIG website.   

The OIG’s decision to exclude can be appealed to an U.S. Department of Health and Human Services (HHS) Administrative Law Judge (ALJ). Adverse decisions by an ALJ can then be appealed to the HHS Departmental Appeals Board (DAB). Individuals may also seek judicial review of any final decision by the DAB.

II.  Imposing OIG Exclusions

There are actually four different administrative processes for permissive exclusions and all of them differ from the process detailed above. As described below, the process utilized for permissive exclusions is dependent on the reason for the exclusion.

OIG may consider imposing a permissive exclusion for submitting claims for excessive charges, unnecessary services, services which fail to meet professionally recognized standards of health care, or the failure of an HMO to furnish medically necessary services.[2] The person or entity to be excluded has a right to request an opportunity to present oral argument to an OIG official before a decision may be reached. The request must be made after the individual or entity receives the Notice of Intent to Exclude, and as an addition to the right to submit evidence in writing.

OIG is not required to send the individual or entity a Notice of Intent to Exclude if it considers imposing a permissive exclusion for the failure to grant immediate access,[3] or for the failure to take corrective action.[4] Instead, OIG will send a Notice of Exclusion that includes information about the right to appeal. The exclusion becomes effective 20 days after the Notice of Exclusion is mailed and notice is provided to the public on OIG’s website. Importantly, the same appeals process that applies to mandatory OIG exclusions also applies to permissive exclusions. 

III. Conclusion

Finally, if OIG is considering excluding a person or entity for fraud, kickbacks or other prohibited activity,[5] OIG will again initiate the process by sending a Notice of Proposal to Exclude. This notice will include information about the basis for the proposed exclusion, the length of the exclusion period, the factors OIG considered when setting the exclusion period, the effect of the exclusion, appeal rights, and reinstatement information. In this situation, the exclusion goes into effect 60 days after the individual or entity receives the Notice of Proposal to Exclude, unless the individual or entity enters a timely request for a hearing. If there is a request for a hearing, the exclusion will not be effective until an ALJ upholds OIG’s decision to exclude. Adverse decisions by an ALJ may be appealed to the DAB and judicial review is available after the DAB enters a final decision.

Need help conducting your required monthly Exclusion Screeing process? Call us at 1-800-294-0952 or fill out the form below to hear how we can help your organization!

 



 


Click to read more on OIG Exclusions

Imposing OIG Exclusions 

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.


[1] Dep’t of Health and Human Servs. Office of the Inspector Gen., Exclusions FAQ, https://oig.hhs.gov/faqs/exclusions-faq.asp (last accessed November 26, 2014).
[2] Section 1128(b)(6) of the Social Security Act.
[3] § 1128(b)(12).
[4] § 1128(b)(13).
[5] § 1128(b)(7).

Do I really Need to Screen My Employees and Vendors Each Month?

female doctor performing her monthly screening of employees
I.  OIG Recommends Monthly Screening

   While there is not a formal regulation that mandates monthly exclusion screening, OIG issued guidance in May 2013, which recommended that providers check their employees and contractors against the OIG-LEIE each month because the LEIE is updated on a monthly basis. Just how many new names could possibly be added to the LEIE each month? According to Modern Healthcare, OIG adds approximately 300 new names to the LEIE every month.[1]  Providers are reminded that if OIG discovers that a provider billed for items or services provided by an excluded individual, it may impose CMPs up to $10,000 for each item or service billed to the Federal health care programs. So, while it is not necessarily mandatory at the Federal level, monthly screening is in every provider’s best interest, especially with such a large number of names being added to the LEIE each month.

II.  14 States Require Monthly Screening

   Furthermore, monthly screening IS mandatory in at least fourteen states, while many others strongly suggest providers screen employees and vendors against their state list and the LEIE monthly.

   For example, Hawaii states on its Medicaid website that any provider who participates in the Medicaid program must search Hawaii’s excluded provider list monthly and the LEIE on an annual basis to determine whether an employee or contractor has been excluded from participation in the Medicaid program. Kentucky mandates monthly screening against Kentucky’s state Medicaid list, the OIG-LEIE, and the GSA-SAM.[2]  New Jersey made exclusion searches mandatory in 2010.[3] New Jersey providers and HMOs are responsible for verifying all “current and prospective employees (regular or temporary), contractors or subcontractors who directly or indirectly will be furnishing, ordering, directing, managing or prescribing items or services in whole or in part are not excluded, unlicensed or uncertified by searching the following databases on a monthly basis:”  OIG-LEIE, NJ Treasurer’s Exclusions Database, NJ Division of Consumer Affairs licensure database, NJ Department of Health and Senior Services licensure database, Certified Nurse aide and personal care assistant registry, and National Provider Database (NPDB).

   Providers are reminded that if you are a provider in North Carolina and one of your employees is on Hawaii’s excluded provider list, then you have violated the exclusion provisions. Under ACA Section 6501, an individual or entity that is excluded from one state’s Medicaid program is excluded in all states. So, yes providers really do need to conduct exclusion screening checks of the LEIE, GSA-SAM, and all 38 state lists on a monthly basis.

Feel free to contact the exclusion experts at Exclusion ScreeningSM at 1-800-294-0952 or fill outthe form below for a free consultation.



 


[1] Joe Carlson, Exclusion Efforts – OIG Pushes for monthly blacklist cross-check, Modern Healthcare (May 18, 2013, 12:01 AM). http://www.modernhealthcare.com/article/20130518/MAGAZINE/305189975/exclusion-efforts?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMWGJVZndKRWxYOU9qTENvK25lK0g4UktiMnBlMDVva2d3YytteWJHZUU0akNYWm85ZStYYzJoUkE9PQ==.

[2] KY Medicaid Program Terminated and Excluded Provider List, KY Cabinet for Health and Family Servs. Dep’t for Medicaid Servs. http://www.chfs.ky.gov/dms/term.htm (last accessed July 21, 2014).

[3] Newsletter to All Providers and All Health Maintenance Organizations from the NJ Dep’t of Human Servs., 20 Excluded, Unlicensed or Uncertified Individuals or Entities (Oct. 2010).