OIG/CMS Requirements

Guidelines for health care providers to screen employees, contractors and vendors monthly against LEIE exclusion list.

“To avoid potential CMP liability, providers should check the LEIE (List of Excluded Individuals and Entities) prior to employing or contracting with persons and periodically check the LEIE to determine the exclusion status of current employees and contractors. OIG updates the LEIE monthly, so screening employees and contractors each month best minimizes potential overpayment and…

OIG imposes large fines, monetary penalties and possible program exclusion upon providers that employ or enter into contracts with excluded persons or entities to provide items or services payable by Federal health care programs.

“BBA (Balanced Budget Act, 1997) authorized the imposition of CMPs (Civil Monetary Penalties) against providers that employ or enter into contracts with excluded persons to provide items or services payable by Federal health care programs. If a health care provider arranges or contracts (by employment or otherwise) with a person that the provider knows or…

Items and Services that Excluded Parties May Be Furnishing Which Will Subject Their Employer or Contractor to Possible Civil Monetary Penalty (CMP) Liability

“Set forth below is a listing of some of the types of items or services that are reimbursed by Federal health care programs which, when provided by excluded parties, violate an OIG exclusion. These examples also demonstrate the kinds of items and services that excluded parties may be furnishing which will subject their employer or…

Medicare/Medicaid payments are prohibited to providers who furnish any items and services at the medical direction or on the prescription of an excluded person.

“Any items and services furnished at the medical direction or on the prescription of an excluded person are not payable when the person furnishing the items or services either knows or should know of the exclusion. This prohibition applies even when the Federal payment itself is made to a State agency or a provider that…

Providers are responsible to ensure that the ordering or prescribing physician is not excluded from participation in Medicare/Medicaid.

“Many providers that furnish items and services on the basis of orders or prescriptions, such as laboratories, imaging centers, durable medical equipment suppliers, and pharmacies, have asked whether they could be subject to liability if they furnish items or services to a Federal program beneficiary on the basis of an order or a prescription that…

CMS Licensure Requirements for Medicare and Medicaid Providers and Suppliers

“Over the past several years, we have taken a number of steps to strengthen our ability to deny or revoke Medicare billing privileges when providers or suppliers do not have or do not maintain the applicable State licensure requirements for their provider or supplier type or profession… To ensure that only qualified providers and suppliers…

OIG recommends contractors be screened by providers or validate that the contractor is conducting proper screening on behalf of the provider to avoid liability.

“OIG recommends that providers screen nurses provided by staffing agencies, physician groups that contract with hospitals to provide emergency room coverage, and billing or coding contractors. The provider could choose to rely on screening conducted by the contractor, but OIG recommends that the provider validate that the contractor is conducting such screening on behalf of…

Providers liable for exclusion penalties even if they use a third party to perform their exclusion screening.

“Some providers may choose to contract with another entity to perform their screening against the LEIE. These providers should be aware that because it is the provider’s responsibility to determine whether employees are excluded, the providers will retain the potential CMP liability if they employ or contract with an excluded person.” OIG Special Advisory Bulletin…

Medicare/Medicaid payments are prohibited to healthcare providers if an excluded individual or entity is serving in an executive or leadership role or providing other administrative and management services for the provider.

“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…

Prohibition on Medicare/Medicaid payments includes ancillary medical services provided by excluded individuals or entities.

“The prohibition on Federal health care program payment for items or services furnished by an excluded individual includes items and services beyond direct patient care. For instance, the prohibition applies to services performed by excluded individuals who work for or under an arrangement with a hospital, nursing home, home health agency, or managed care entity…