Screening And Evaluation Of Employees Physicians Vendors And Other Agents
This section includes ideas for measuring how well organizations evaluate employees, vendors, and affiliated individuals for possible exclusion and conflicts of interest, and whether the organization has a plan for responding to these issues. The metrics remind organizations that an effective healthcare compliance program concerns not only the organizations own employees, but also the organizations third-party vendors, agents, and affiliated individuals.
Iv Some States Require Screening Extraneous Lists
V. A Simple and Affordable Solution
Without a doubt, state and federal exclusion screening requirements are incredibly burdensome for most providers. If screening your employees against each federal and state list that your state requires is not cost effective for your office to do in-house, contact Exclusion Screening, LLC today at 1-800-294-0952 or fill out our online service form found below. We would be happy to discuss your specific state obligations, provide a cost assessment, and help you create your employee and vendor list.
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Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.
See Letter from Centers for Medicare and Medicaid Services to State Medicaid Directors 5 .
Newsletter to All Providers, from the New Jersey Dept of Human Servs., et al., Excluded, Unlicensed or Uncertified Individuals or Entities .
Oig Exclusions: To Disclose Or Not To Disclosethat Is The Question
Youve discovered an OIG exclusion blooper. Now what?
If youre like most administrators, youd probably opt to fire the excluded employee, bury the evidence, and hope that the OIG never finds out about it. After all, who in their right mind would actively call the OIGs attention to a mistake like that?!
Anyone who wants to prevent a worse mistake. Thats who.
Under the OIGs self-disclosure clause, contractors are required by law to self-disclose upon discovering an excluded individual within their employee ranks. Failure to self-disclose can result in contractor suspension or debarment. Not something youd want to play around with.
On the face of it, self-disclosure is scary. It means shoving your failures directly under the nose of the OIG, and inviting whatever repercussions may come about as a result.
On the other hand, from a damage-control perspective, self-disclosure is the wisest course of action to take. It may result in fees and fines but it will also protect your company or organization from full-scale suspension, not to mention the whopping fees that are sure to be slapped onto a facility perceived as willfully flouting the law. Self-disclosure gives you the chance to explain and defend yourself before youve been accused.
A confession in time indicates your contrition and willingness to cooperate with the authorities. And in return, the authorities will be that much more likely to cooperate with you.
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Communication Education And Training On Compliance Issues
The Guide provides organizations with tools to measure whether individuals receive effective job-appropriate training, whether the organizations governing body is adequately trained in compliance efforts, and whether that training is updated with necessary regulatory changes or compliance failures. There are also ideas on how to measure whether an organization has established a culture of healthcare compliance.
How Is An Exclusion Screening Search Performed
The employer inputs the employees name and date of birth into the database. The database returns a list of potential matches, including individuals with similar names. The employer must then independently verify whether or not the employee in question is, indeed, the same person as the excluded individual. Employers are also required to check all versions of each employees name, including maiden names, combined names , and name diminutives .
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What Effect Does An Oig Exclusion Reinstatement Have On A Separate State Medicaid Exclusion
If a provider or entity is excluded by both a State Medicaid exclusion authority and the OIG LEIE, then they need to apply for reinstatement at both separately. The State Medicaid exclusion authorities do not remove an individual from the State list just because they have been removed from the OIG LEIE. Even if the reason the OIG added the individual to the LEIE was due to the State Medicaid exclusion, the reinstatement by the OIG has no effect on the separate State Medicaid exclusion and vice versa.
How To Conduct Exclusion Screening
In the Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Healthcare Programs, the OIG provided specific guidance to the healthcare industry on the frequency of screening employees and contractors to determine whether they are excluded persons. While noting that there is no statutory or regulatory requirement to check the OIG LEIE and that providers may decide how frequently to check it, the OIG confirmed that it updates the LEIE monthly, so screening employees and contractors each month best minimizes potential overpayment and CMP liability.
The OIG does not issue individual warnings or notifications regarding excluded individuals. Employers are required to search the Federal exclusions database and SAM.gov, as well as each individual states Exclusion Database, to verify the status of each one of their employees. In addition to this, various states require additional searches as well.
The employer inputs the employees name and date of birth into the database. The database returns a list of potential matches, including individuals with similar names. The employer must then independently verify whether or not the employee in question is the same person as the excluded individual. Employers are also required to check all versions of each employees name, including maiden names, combined names, and name diminutives.
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Standards Policies And Procedures
The Guide highlights the importance of having the relevant policies and procedures in place to form the structure of an organizations healthcare compliance program. The metrics focus on basic compliance functions, including measuring employees access to the policies, implementing internal processes for periodically reviewing the policies, assessing the quality and applicability of the policies, maintaining an organizational code of conduct, and ensuring an organization-wide understanding of healthcare compliance policies and procedures.
Provider Fraud Waste & Abuse
Some examples of provider activity that is monitored for fraud, waste and abuse:
- Prescribing drugs, equipment or services that are not medically necessary
- Billing more than once for the same service
- Intentionally using improper medical coding to receive a higher rate of reimbursement
- Billing for services not provided
- Scheduling more frequent return visits than are needed
- Unbundling services to obtain higher reimbursement
- Purchasing drugs from outside the U.S.
- Prescribing high quantities of controlled substances without medical necessity
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Odm Announces That The Cbhc Medicaid Provider File Is Suspended For Maintenance
A Message from ODM:
In March 2020, the Ohio Department of Medicaid stopped producing the Universal Roster of practitioners affiliated with behavioral health agencies and moved to the MITS Provider Master File as the system of truth for Medicaid provider enrollment.
However, BH providers requested that ODM continue producing and updating the CBHC Medicaid Provider File listing all practitioners affiliated with behavioral health provider agencies. ODM has continued to produce and update the CBHC Medicaid Provider File as a convenience for provider agencies even though they have access to the same information via their secure MITS Portals by reviewing their group members.
The previous CBHC Medicaid Provider File excluded providers whose revalidations dates had expired. However, revalidation dates are not applicable during the COVID public health emergency.
Consequently, the current CBHC Medicaid Provider File is no longer accurate because it excludes practitioners who remain active in Ohio Medicaid. ODM staff are working on a solution to this problem, but until a solution can be developed and implemented, the CBHC Medicaid Provider File will be suspended. This issue should have no impact on MITS and Medicaid Managed Care Plan claims systems.
Ohio Children’s Alliance
Investigations And Remedial Measures
This section includes metrics that organizations may use to evaluate the effectiveness of compliance investigations, including the independence and competence of the investigators, communication regarding investigations, and whether the organization responds appropriately to compliance concerns.
The Resource Guide represents the most thorough presentation of the OIGs thinking on compliance program evaluations. As such, it can be used as a starting point for healthcare compliance program assessment tools, regardless of the type of organization conducting the evaluation.
OIG Healthcare Compliance Law
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What Are The Effects Of Exclusion
The principal effect of exclusion is that payment is prohibited for anything that an excluded individual furnishes, orders, or prescribes, and any administrative and management services furnished by the excluded individual. This prohibition extends to anyone who employs or contracts with the excluded individual.
The OIG provides an in-depth review of the effects of exclusion in its. The Bulletin sets forth the following specific instances where payment of items and services are prohibited with Federal healthcare program funds:
Oigs Administrative Process For Imposing Exclusions
Exclusions under Section 1128
When OIG is considering the exclusion of an individual or entity under section 1128 of the Act, the administrative process is governed by regulations codified at 42 CFR sections 1001.2001 through 1001.2007. However, depending on the basis for the proposed exclusion, the process can vary.
For all proposed mandatory exclusions that are longer than the mandatory minimum five-year period, and most proposed permissive exclusions, the administrative process is the same. OIG sends out a written NOI to any individual that they are considering excluding. The NOI includes the basis for the proposed exclusion and a statement about the potential effect of exclusion.
The NOI is pre-decisional and allows the individual or entity 30 days to respond in writing with any information or evidence relevant to whether the exclusion is warranted and to raise any other related issues, such as mitigating circumstances. OIG considers all available information in making a final decision about whether to impose the exclusion.
Exclusions under Section 1128
When a permissive exclusion is being considered under section 1128 of the Act, the NOI allows the individual or entity to request an opportunity to present an oral argument to an OIG official before a decision about whether to execute is reached. This is in addition to the right to submit documentary evidence and written argument.
Exclusions under Section 1128
Exclusions under Section 1156
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Pharmacy Fraud Waste & Abuse
Examples of pharmacy fraud, waste and abuse:
- Prescription drugs not dispensed as written
- Submitting claims for a more expensive brand-name drug when a less expensive generic prescription is dispensed
- Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees
- Splitting prescriptions into two orders to seek higher reimbursement
- Dispensing expired, fake, diluted or illegal drugs
- Billing for prescriptions not filled or picked up
What Are The Different Types Of Oig Exclusions
There are two types of exclusions:
- Mandatory Exclusions are meted out as penalties for health care fraud/crimes, patient abuse, or unlawful distribution of controlled substances. The Office of Inspector General is legally required to exclude individuals or entities convicted of such crimes for a minimum of five years.
- Permissive Exclusions are mandated as penalties under 16 different authorities and may be issued due to loss of state license to practice, failure to repay student loans, conviction of certain misdemeanors, failure to provide quality care, or one of several other misdemeanors.
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Are Exclusions Permanent
While getting on the OIGs list of excluded individuals can pose some serious problems for personal credibility and financial stability, it is not an irreversible situation.
At the end of the OIG exclusion term, the affected provider needs to apply for reinstatement to receive an authorized notice from the OIG stating the request was granted. Excluded providers may only begin the process of reinstatement 90 days before the end of the excluded period. Premature requests for reinstatement will not be considered, so it is important to be careful when to apply.
Penalties For Oig Non
Providers that employ or contract with individuals or entities that such provider knows or should know are excluded from participation in federal healthcare programs may be subject to different penalties.
The OIG assesses civil fines and monetary penalties.
The penalties for allowing services to be performed by an excluded individual or entity can include:
- $10,000 per each item claimed or services provided
- Treble damage
- Possible program exclusion of the healthcare organization
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Member Fraud Waste & Abuse
CareSource monitors member activity for fraud, waste and abuse. Some examples are:
- Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
- Sharing a member ID card
- Obtaining unnecessary equipment/supplies
- Changing prescription forms to get more than the amount of medication prescribed by their physician
- Member receiving services or picking up prescriptions under another persons ID
Seventh Database For Background Checks
Amendments to rules 173-9-03 and 173-9-03.1 of the Administrative Code took effect March 1, 2019.
Since 2013, the rules have required reviewing the status of persons being checked in six databases. One of the amendments will require checking a seventh database, the Medicaid Provider Exclusion & Suspension List. The Ohio Department of Aging amended the rules to require the seventh database to keep standards for disqualification the same between ODA and the Ohio Department of Medicaid, which already disqualifies persons on the Medicaid exclusion list.
- For an individual hired by an ODA-certified provider on or after March 1, 2019, the provider will be required to check all seven databases upon hire.
- For an employee of an ODA-certified provider hired prior to March 1, 2019, the provider will not have to check the seventh database until the provider conducts the next criminal records check on the employee. OAC rule 173-9-04 allows a provider to wait until the fifth anniversary of the employees date of hire before conducting a new set of criminal records checks.
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List Of Sanctioned Providers
Pursuant to Section 1128 and Section 1902 of the Social Security Act, the Medicaid Program will not reimburse a provider for any services or items that were rendered or ordered/prescribed by a sanctioned provider. The effect of the provider’s sanction precludes them from furnishing, ordering, or prescribing services or items to any Medicaid beneficiary. Claims for services/items rendered/ordered/prescribed by a sanctioned provider with dates of service or dispensing after the effective date of the sanction, will be rejected or disallowed if discovered during a post-payment review. Refills of prescriptions written by a sanctioned provider must not be dispensed beyond the effective date of the sanction letter. Claims for services/items rendered/ordered/prescribed by a provider for whom sanctions have been removed will be honored retroactively to the date the sanction ended.
Sanctioned Provider List
The MDHHS Sanctioned Provider List reflects the sanctioned provider’s name, NPI , license/certification number if applicable), along with the sanctioning authority, sanction date and reason for sanction*. As additions and deletions are made to the list, the changes will be published in the listing below. MDHHS does not publish paper copies of the complete listing.
Supplemental Sanctioned Information
*Definitions of HHS sanctions are available at www.ssa.gov/OP_Home/ssact/title11/1100.htm
How Does An Employer Find Out If An Individual Or Entity Is Excluded
The OIG does not issue individual warnings or notifications regarding excluded individuals. Employers are required to search the Federal exclusions database and SAM.gov, as well as each individual states Medicaid Exclusion Database, to verify the status of each one of their employees. Various states require additional searches as well.
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Ohio Medicaid And Managed Care Organizations
Today, more than 90 percent of Ohio Medicaid members are supported by managed care organizations . During the year ahead, ODM will begin implementing a new vision for care focusing on the individual, a strong partnership among MCOs and the department, and supporting specialization in addressing critical needs.
What Is Healthcare Compliance
Healthcare compliance is the ongoing process of meeting the legal, ethical, and professional standards applicable to a particular healthcare organization or provider. To be compliant, healthcare organizations and providers need to develop effective processes, policies, and procedures to define appropriate conduct, train the organizations staff, and monitor the adherence to defined policies. Healthcare compliance covers numerous areas including patient care, billing, reimbursement, HIPAA privacy and security, and many more.
The governing body and the executive officers of the healthcare organization bear the ultimate responsibility for its compliance or lack of it. The organizations governing body is responsible for directing the organizations administrators to develop and implement the healthcare compliance program together with authorizing funds to accomplish the task.
While the governing body, the compliance officer, and the compliance committees have primary responsibility for the organizations compliance program, every employee is responsible in their own way for healthcare compliance, and the success of the program. Accordingly, individual members of the organization need to report any healthcare compliance concerns they have up the chain of command and report anything that appears to be out of the ordinary, unusual, or questionable.
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