It is the mission of the Department of Health and Human Services (HHS) to enhance and protect the health and well-being of Americans. As a part of their authority, HHS determines who will receive the benefits from these programs, as well as who will be allowed to provide services to these individuals. HHS has delegated the authority to exclude individuals from participating in any federal of state healthcare programs to the Office of the Inspector General (OIG). The OIG’s mission is to protect the integrity of HHS programs, and the health and welfare of program beneficiaries. The OIG has been tasked with fighting waste, fraud, and abuse in HHS programs, such as Medicare and Medicaid. Consequently, the OIG has the authority to impose sanctions to individuals or entities that have been found to be unacceptable risks to patient safety and/or program fraud. Being excluded means that you will not be paid for any item or service you have directly or indirectly furnished or performed for beneficiaries of federal or state healthcare programs.
Types of Exclusions
There are two types of OIG exclusions: mandatory and permissive.
Mandatory exclusions last a minimum of 5 years and are imposed on a person or entity that is convicted of certain criminal offenses: (1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, CHIP, or other State health care programs; (2) patient abuse or neglect; (3) felony convictions for other health care-related fraud, theft, or other financial misconduct; (4) felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
Permissive (discretionary authority) exclusions can be imposed on a number of grounds, including (but not limited to): (1) misdemeanor convictions related to health care fraud other than Medicare or a state healthcare program, fraud in a program (other than a healthcare program) funded by any federal, state or local government agency; (2) misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; (3) suspension, revocation, or surrender of a license to provide healthcare for reasons bearing on professional competence, professional performance, or financial integrity; (4) provision of unnecessary or sub-standard services; (5) submission of false or fraudulent claims to a federal healthcare program; (6) engaging in unlawful kickback arrangements; (7) defaulting on health education loan or scholarship obligations; (8) controlling a sanctioned entity as an owner, officer, or managing employee.
Providers participating in federal and state healthcare programs and Business Associates, such as billing companies, are required to ensure that their employees, contractors, and vendors have not been excluded. Any claim that might involve an excluded person or entity could have False Claims Act implications under the Affordable Care Act. So inadvertent violations must be reported and all money that has been paid on the claims are overpayments and need to be returned. Additionally, the OIG also has the authority to impose civil monetary penalties (CMPs) of up to $21,562.80 for each item or service furnished by the excluded person or entity, as well as assessments of up to 3 times the amount claimed. To avoid placing yourself at risk of massive sums of dollars, we highly recommend that you perform these screenings, which should be done on a monthly basis, as well as at the time of a new hire (Physician Revenue Navigators screens potential candidates before the hiring process to ensure that the candidates are qualified).
Conducting the Screenings
The screenings must be done for both federal and state programs. The checks must be done through federal databases (OIG and SAM) as well as against each available state database (not all states have databases). Doing your own screenings can be cumbersome because the state databases are not uniform and may not be updated regularly. Physician Revenue Navigators perform these required screenings through our partner, Exclusion Screenings, LLC.
Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities. We place great importance in being compliant with governmental regulations. Contact us to learn more about how we can help you gain more revenue within the scope of compliance.