As a health care provider, you take pride in your efforts to fulfill all your many compliance requirements. You have employees within your organization whose sole responsibility it is to screen all your employees monthly against the List of Excluded Individuals and Entities (LEIE) to comply with the guidelines and recommendations established by the Office of the Inspector General (OIG).
Isn’t that enough?
Unfortunately for you, that is just scratching the surface! If you are an approved provider for any Federal health care programs (Medicare, Medicaid, Tri-Care, et al) and receive payments for claims from these programs, you must be aware of the following effects of exclusion from participation in Federal health care programs as clarified in an OIG Special Advisory Bulletin issued May 8, 2013:
- Medicare/Medicaid payment for items or services furnished or ordered by an excluded individual or entity is prohibited.
“The effect of an OIG exclusion is that no Federal health care program payment may be made for any items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person. The exclusion and the payment prohibition continue to apply to an individual even if he or she changes from one health care profession to another while excluded. This payment prohibition applies…even if the payment is made to a State agency or a person that is not excluded.”
- 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 when such services are related to, for example, preparation of surgical trays or review of treatment plans, regardless of whether such services are separately billable or are included in bundled payment.
- Another example is services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling prescriptions for drugs that are billed to a Federal health care program.
- Also, excluded individuals are prohibited from providing transportation services that are paid for by a Federal health care program, such as those provided by ambulance drivers or ambulance company dispatchers.”
- 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 counsel, director of health information management, director of human resources, physician practice office manager, etc.) at a provider that furnishes items or services payable by Federal health care programs.
- Also, an excluded individual may not provide other types of administrative and management services, such as health information technology services and support, strategic planning, billing and accounting, staff training, and human resources, unless wholly unrelated to Federal health care programs.”
- 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 is not excluded.”
- 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 was written by an excluded physician. Payment for such items or services is prohibited. Providers should ensure, at the point of service, that the ordering or prescribing physician is not excluded.”
- 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 should know is excluded by OIG, the provider may be subject to CMP liability, if the excluded person provides services payable, directly or indirectly, by a Federal health care program. OIG may impose CMPs of up to $10,000 for each item or service furnished by the excluded person for which the Federal program payment is sought, as well as an assessment of up to three times the amount claimed, and program exclusion.”
“A provider could be subject to CMP liability if an excluded person participates in any way in the furnishing of items or services that are payable by a Federal health care program…including direct patient care, indirect patient care, administrative and management services, and items or services furnished at the medical direction or on the prescription of an excluded person when the person furnishing the services either knows or should know of the exclusion.”
“CMP liability could result if the provider’s claim to the Federal health care program includes any items or services furnished by an excluded person, even if the excluded person does not receive payments from the provider for his or her services (e.g. a non-employed excluded physician who is a member of a hospital’s medical staff or an excluded health care professional who works at a hospital or nursing home as a volunteer).”
“An excluded person may not provide services that are payable by Federal health care programs, regardless of whether the person is an employee, a contractor, or a volunteer or has any other relationship with the provider.
- For example, if a hospital contracts with a staffing agency for temporary or per diem nurses, the hospital will be subject to overpayment liability and may be subject to CMP liability if an excluded nurse from that staffing agency furnishes items or services to Federal health care program beneficiaries.”
- Requirement 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 CMP liability. Additionally, in January 2009, CMS (Center for Medicare and Medicaid Studies) issued a State Medicaid Director Letter (SMDL) recommending that States require providers to screen all employees and contractors monthly. In 2011, CMS issued final regulations mandating states to screen all enrolled providers monthly.”
- 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 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 the provider (e.g., by requesting and maintaining screening documentation from the contractor). Regardless of whether and by whom screening is performed and the status of the person (e.g., employee, subcontractor, employee of the contractor, or volunteer), the provider is subject to overpayment liability for any items or services furnished by any excluded person for which the provider received Federal health care program reimbursement and may be subject to CMP liability if the provider does not ensure that an appropriate exclusion screening was performed.”
WOW!! The OIG recommends that you conduct monthly screenings on all of all your employees, volunteers, board members, referring physicians, contractors and vendors for exclusions, both nationally and in each of the 50 states. You must be wondering by now how you could possibly meet all these recommendations and requirements and stay in full compliance with the OIG. The answer is to become a client of ExclusionALERT™. Our clients know that by utilizing the full line of professional services provided by ExclusionALERT™, they are guaranteed to be 100% compliant with all current and future OIG/CMS requirements. And we are so confident of the quality of our ExclusionALERT™ programs that we provide our clients with our exclusive Sanction Shield™ offering them 100% liability coverage…guaranteed!
Visit our website at www.exclusionalert.com to learn more about what we can do for you and contact us so that we can begin working with you immediately to eliminate all your risk and exposure of non-compliance sanctions.