OIG Exclusion Monitoring Services

OIG Exclusion List Monitoring

Healthcare compliance continues to grow more complex. Your risk grows from a steady flow of new guidelines, oversight, and regulations.

One driver for this is health care services reimbursed by the federal tax dollars. The DOJ (Department of Justice) and DHHS (Department of Health and Human Services), have oversight on how these dollars are spent and focus on the enforcement of health care fraud, waste, and abuse.

An Office of Inspector General (OIG) exclusion is an administrative action taken against an individual or entity (such as a provider or vendor) by the Department of Health and Human Services (HHS), Office of Inspector General (OIG).

The HHS OIG is in charge of enforcing exclusions against individuals or entities. Should a person or entity be excluded, they are prohibited from participating in reimbursements for or from federally funded healthcare programs (CMS.gov – Centers for Medicare & Medicaid Services).

 

The exclusion* is effective in all US states – not just the state where the person or entity happens to receive the exclusion notice.

There are currently a total of 44 States with a database for the purposes of excluding individuals and entities if they are found to have misused or misappropriated monies from Medicare and Medicaid.

Each of these States are required to push all excluded individuals and entities to the OIG federal database, but this update varies by state and frequency. Some States delay this update by 18 months, or in some cases even longer. An employer receiving federal funds, such as firms in the healthcare industry, is expected to check all employees, contractors, and vendors against each database on a routine basis for any listing of possible fraud.

According to the Affordable Care Act any entity, individual or vendor excluded in a state list is not allowed to participate in the federal Healthcare funds of other states. This so-called "excluded in one, excluded in all” position places the burden to searching the list of excluded individuals on the employer - a formidable task.

All State and Federal lists containing excluded individuals are public knowledge and free to access. Because the information is public knowledge, every employer is expected to be compliant for all exclusions databases. An argument of 'the employer should have known’ is nearly impossible to refute should things get to the point of an investigation or inquiry.

The question becomes how employers can conceivably check all 47 databases on a regular basis for both individuals and entities effectively; following up on anyone showing up on a list to ensure it is their employee.

Some of the lists have very little information on the excluded individual, making it hard to determine with certainty that it’s the same person currently working for said employer.



The consequences of exclusion are assessed by the OIG and can be significant:

  • $10,000 Per Item Services or Claims Provided
  • Statutory Treble Damages (i.e., three times the amount of the false claim)
  • Possible exclusion program of the organization
  • Offers Approximate Loss of the Right to Bill CMS for Services
  • Possible Filing of False Claims Count Under the False Claims Act
  • Probable Criminal Jail or Fines

IES offers many solutions focused on maintaining the health and wellness of your employees.

*Exclusions are actions taken against an individual or vendor/entity by the Department of Health and Human Services, Office of Inspector General (OIG), and participating States.

IES provides Employers assurances that all mandatory exclusion lists are monitored daily for any activity and should a record surface of an excluded individual or entity, that we have the tools to verify whether the employee, contractor or entity matches the hit.

Further, IES provides Employers with additional documentation, court records, screen shots, etc., in the event of an audit by a State or Federal agency. A verified hit requires an Employer to remove excluded individuals and entities from any participation where federal funds are accessible. Often this requires terminating the employee or selecting another vendor with whom to do business.

Can your organization afford to monitor 3 federal databases AND 43 state databases?
Can your organization afford not to?

 
 

OIG Exclusion List Monitoring

It is the employer’s responsibility to monitor this activity by checking ALL exclusion databases monthly. Remember the OIG mandates that healthcare organizations do not hire or do business with “excluded or sanctioned” individuals or entities, so employees AND vendors must be searched every month if an organization is to remain fully compliant!

That is a lot of work, and risk.

Our real-time Exclusion monitoring service removes the responsibility and burden of monthly monitoring of all exclusion databases and provides complete reporting, so you can focus on other priorities without the fear of the potential penalties of doing business with excluded person or entity.

 
 

It all starts with an understanding of your business

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