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OIG Exclusions Screening: Best Practices for Healthcare

April 27, 2021 | By Linda Pophal

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Healthcare is an industry, perhaps more than most others, that is particularly prone to concerns about how individuals’ past behaviors could predict, or impact, their future interactions. It’s an industry, after all, that involves not just working with people but interacting with them at times when they are often at their most weak and vulnerable.

It’s a highly regulated industry and for good reason. The health, wellness, and even lives of individuals seeking care from healthcare providers lie in the balance. Regulatory bodies are highly attuned to the importance of ensuring that those who are tasked with treating others do not have backgrounds that might call into question the quality of that treatment — like patient abuse or neglect, certain types of crimes, fraud, and the use of controlled substances.

Healthcare organizations are, therefore, understandably concerned that the individuals they both hire and retain have no blemishes in their backgrounds that could put patients and others at risk. There are monetary considerations as well, specifically related to reimbursement from government-funded healthcare programs.

OIG Exclusions Screening

The Office of Inspector General (OIG) has the ability to exclude individuals and entities from receiving funding from Federal healthcare programs. OIG exclusions are based on actions brought for a range of reasons. The OIG maintains a list of individuals and entities that have been excluded in an online searchable database.

Organizations that hire someone who is on the list can be subject to civil monetary penalties (CMP). But even those who were hired before their name appeared on the list may appear later; at that time the organization they work for is still on the hook.

That’s where the importance of having an ongoing process for routinely checking the OIG database comes into play.

How the Exclusion Process Works

You may wonder how it could be that you might hire someone whose name didn’t appear on the list at the point of hire, but who show up during their term of employment with you. It has to do with the way the OIG exclusion process works.

At the point that some issue has been identified the OIG will issue a Notice of Intent to Exclude (NOI) to the individual or entity at question. The NOI, though, doesn’t mean that they will automatically be excluded. They have the opportunity to contest the claim which may make its way to an administrative law judge for review.

This can take time. Months, in fact. During that time the individual facing a potential exclusion could be well entrenched in your organization, seeing many patients and representing a significant percentage of your monthly billings. Even if an individual or entity loses their appeal and their name goes on the list, depending on the issue, they may be removed from the list at some later point in time.

It’s a fluid process that employers must be on top of.

Employers are responsible for ensuring that those they employ do not appear on the List of Excluded Individuals/Entities (LEIE). The LEIE is an online searchable database that can also be downloaded and used by healthcare organizations to conduct checks to ensure that nobody on their staff is on the list. Files are updated monthly.

What Can Happen if Your Staff are on the List

In April 2021 the U.S. Attorney’s Office District of Connecticut issued a news release stating that the healthcare company had reached a settlement requiring them to pay $28,246 because they had hired and employed a physical therapist who was excluded in 2015 but hired in 2018.

To avoid the risk of costly and unnecessary penalties like this, it’s important to establish an effective OIG compliance process. The National Law Review offers some tips for healthcare organizations about how to establish and document compliance efforts:

  • Make sure your processes are customized to your unique needs. Applying an “off-the-shelf” solution is not sufficient to ensure protection.
  • Consider appointing someone to serve in a Chief Compliance Officer, or similar, role.
  • Be sure to have standards of conduct in place for all of your staff.
  • Put training and communication practices in place that are ongoing and not simply a “one and done” approach
  • Ensure that any contracts with third parties and independent physicians are sufficient to protect your organization.
  • Take steps to ensure that your billing compliance programs are effective.
  • Monitor OIG fraud alerts.
  • Conduct internal compliance audits.
  • Have a process in place to ensure that compliance is being taken into account when making employment decisions—e.g., promotions, disciplinary actions or terminations.
  • Establish a process for ensuring ongoing document of compliance.

OIG compliance is complex and challenging for even the most sophisticated healthcare systems. But it’s a necessary evil to protect your interests and the interests of your patients and staff members. Putting the steps above in place, or evaluating your current processes, can be an important best practice to minimize risk.

Or work with a company like Accurate to provide the protection and peace of mind you need to avoid potential OIG penalties.

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