Making Sanction Screening a Priority of a Compliance Program

Why make sanction screening a priority? Although the HHS “Office of Inspector General (OIG) identified sanction screening issues as a risk area in its original compliance program guidance documents issued over a decade ago,” in the last few years enforcement of compliance has been given a high level of importance, according to Camella Boateng, MPH, consultant and analyst Strategic Management Services, LLC (SMS).  Health care organizations receiving federal payments from the Medicare and Medicaid programs must move sanction screening up in the priority order of ongoing monitoring and auditing, Boateng stressed in her article, “It Is Imperative to Understand Fully the Significance of Failing to Conduct a Thorough Review,” in the Journal of Health Care Compliance (Volume 13, No. 4, July-August, 2011).

Under program integrity regulations, no payment will be made by Medicare, Medicaid, or any of the other federal health care programs for any items or service furnished by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual who is excluded when the person furnishing such item or service knew or had reason to know of the exclusion. This prohibition remains in effect until the individual or entity has been reinstated to participate in federal health care programs in accordance with the reinstatement regulations.  

Consequences of Failure to Screen

Health care organizations that fail to conduct thorough and regular reviews for excluded providers risk large financial penalties and revoked billing rights. The payment ban for sanctioned individuals or entities applies to all methods of the federal program reimbursement including claims, cost reports, fee schedules, and prospective payment system (see “The Effect of Exclusion from Participation in Federal Health Care Programs,” OIG Special Adviory Bulletin, September 1999). When a violation has been identified, there is no investigation, OIG imposes a civil money penalty on the provider who has employed or contracted with an excluded individual or entity. In the last three years, there have been more than 60 civil monetary penalty cases resulting in over $10 million in settlements with penalties ranging up to $300,000 per excluded individual identified, Boateng explained.

Screening Sites

HHS exclusions, which are administered by OIG, are maintained for public viewing on the List of Excluded Individuals and Entities (LEIE).  The federal General Services Administration (GSA) maintains a comprehensive database of all federal exclusions in its Excluded Parties List System (EPLS). Exclusion by one federal agency has the effect of exclusion from all other federal programs. OIG expects, at a minimum, that health care organizations will screen their employees and business partners against these databases to ensure that none are under exclusion by the federal government. In itsSpecial Advisory Bulletin, OIG  advised health care provider to avoid potential liability check the List of Excluded Individuals and Entities on the HHS-OIG web site. 

Enforcement Initiatives

Under the OIG Work Plan for 2011, OIG will review Medicaid payments to providers and suppliers to determine the extent to which payments were for services provided during periods of termination or exclusion from the Medicaid program.

Under the Excluded Provider Project, which commenced in 2008, OIG in collaboration with the U.S. attorneys’ offices in New England identify entities submitting claims for items and services rendered by excluded providers.

Under the Patient Protection and Affordable Care Act (PPACA), CMS must establish a process to inform state Medicaid and Children’s Health Insurance Program plans of providers terminated from the Medicare program. In addition, states must terminate providers participating in their Medicaid plans if the providers have been excluded from Medicare or another state Medicaid program.

Integrating Screening into a Compliance Program

Health care providers should utilize key elements of an effective compliance program to ensure the screening process is successfully integrated into their operations. The elements of an effective excluded parties screening program borrow from the elements of an effective compliance program: adopting written standards, providing education and training, auditing and monitoring, and responding to detected deficiencies. Each organization should integrate the screening process to meet its own needs, ensuring the following types of individuals and entities are screened: (1) those with ownership or control; (2) those with access to patients, patient information, patient belongings; (3) those with contracts (whether written or oral); and (4) those with the ability to order patient care tests or services.

Boateng advised health care organizations to take steps to avoid employing or contracting with excluded individuals or entities to remain compliant and reduce potential liability and recommended that organizations:

  • Make screening of affected parties with whom the organization is involved against the OIG LEIE and GSA a high priority;
  • Not rely only on federal lists of excluded providers because not all state enforcement actions are reported to the OIG, rather review multiple states, including the individual’s previous state of employment, to ensure thorough sanction screenings; and
  • Conduct sanction screenings prior to hiring or contracting with an individual or entity and periodically thereafter for all affected parties, including checks should be made for physicians applying for staff privileges by the credentialing committee as well as those responsible for contracting for services and products.