From the Contributor’s Corner: Biggest Mistakes With Sanction Screening

With the Office of Inspector General (OIG), CMS, and State Medicaid Agencies all calling for increased and more frequent sanction screening, it is not surprising that providers responded by placing more emphasis on their efforts.  This has become a costly effort, whether done internally or contracted out to a vendor.  Furthermore, in some cases, particularly with hospitals, there are cases where this effort may have gone too far.   It is increasingly common for organizations to screen individuals and entities unnecessarily and in some cases, it is counter-productive or worse.

The most common examples are excessive screening (1) against the General Services Administration (GSA) System for Award Management (SAM) [formerly the Excluded Parties List System (EPLS)] and (2) of physicians who refer patients to the hospital, but are not employed by or do not have staff privileges at the hospital.

General Services Debarment Data

For the GSA database, there are several difficulties associated with sanction screening:

  • The design/purpose of the GSA data is for government agency use only.
  • Relatively few health care providers are a Federal government agency, or a grantee.
  • GSA provides no guidance as to how to resolve a potential hit.
  • GSA data lacks identifiable information for easy verification, whereas the OIG List of Excluded Individuals/Entities (LEIE) sanction screening has verification tools to assist with possible hits.
  • Many administrative debarments are only advisory and can be waived by agency heads.
    • There is no explanation where to draw the line in the sanction screening of contractors and vendors, and even smaller hospitals may have many thousands of them .
    • GSA “hits” are common, but legitimate ones are very uncommon.
    • Confirmed GSA hits provide little ground for terminating a contract, yet can’t be ignored.
    • Technical difficulties for GSA transition from EPLS to SAM have complicated it use.

Screening of Physicians

The screening of physicians who are not on staff or do not have staff privileges at a hospital is another problem. Neither CMS nor the OIG call for such screenings.  There are many problems in trying to screen these physicians, including:

  • There may be thousands of different physicians from time to time referring a patient to a hospital where they have no personal contact; the cost of screening all of these and trying to resolve potential hits can be an expensive proposition.
  • Often, the physician who refers a patient to a hospital may not be from the area, may be personally unknown, or may have never referred a patient before and may not do so again.  It is very common for retired persons who spend much of their time in the winter in Florida or other warmer area to be referred by a local physician to the patient’s home area hospital.
  • It is not unreasonable for the hospital receiving the patient to screen the doctor in advance of providing a service, and the hospital will not have any identifiable data on that physician.
  • If there is a confirmed “hit” against the LEIE, there is little the hospital can do about it, other than write  to them not refer anymore patients.
  • If a sanctioned physician referral is made and the hospital knows about it, it is not entitled to payment by Medicare or Medicaid.

Suggestions

  • In both types of situations described above, the best practice is to only screen those that you must and not try to do more than is required.
  • It is difficult to see the logic in screening the local paper and ink supplier, florist, local newspaper, groundskeeping service, etc.  If an organization decides to screen against the GSA debarment data, then make a decision as to where to draw the line regarding who should be in the mix.  The most sound practice for screening against the GSA debarment list would be to have a policy that requires screening any and all individuals and entities that provide medically-related products or services.  Filtering out those that do not meet that criterion would eliminate the great majority of vendors and contractors that are not relevant to health care, while maintaining the spirit of screening against debarments.
  • Trying to screen referrals from physicians who are not employees, on staff, or known to the hospital is not a good practice for the reasons noted above.  Since there is no requirement or obligation to do such screenings, serious consideration should be given to avoiding them.
  • If there are physicians unaffiliated with the hospital that are referring frequently, consideration might be to screen them.  If anyone is found on the sanction list, they should be notified that they must cease referring patients or the OIG would be notified.

Richard P. Kusserow served 11 years as the DHHS Inspector General and currently is CEO of the Compliance Resource Center (CRC) that includes Sanction Screening Services (S³) and Strategic Management Services (SMS) that have been providing specialized compliance advisory services since 1992. For more information, see http://www.strategicm.com/ or call him directly at (703) 535-1411.

Connect with Richard Kusserow on Google+ or LinkedIn.

Copyright © 2013 Strategic Management Services, LLC.  Published with permission.

Comments

  1. Linda Pifer says:

    This is very helpful information. It is difficult to draw the line with various vendors. Currently we do not have a way to filter out those that have little risk within our current system. We have over 3 thousand vendors.

    We are attempting to limit the vendor list. We are looking to decrease our list by using a rolling 3 year window. Could we be more agressive with the date ranges?

    With providers/physicians, we too have a lot of “snow birds” that fly south for the winter. Often these people return with various physician orders mostly involving radiology and laboratory studies/tests. If I understood you correctly, are these orders from other physicians considered “referrals”?

    I would appreciate any light/clarification you can bring to my situation. Many thanks! 🙂

    • Richard Kusserow says:

      Linda, I know that filtering the vendor list along the lines suggested in the blog article is difficult and time consuming, however I think it is worth the effort. Once this effort has been made, it will not need to be done again. Any new vendor can be tagged on the front end as to whether it should be screened or not. I think the effort associated with this approach is preferable to using a three year rolling window. The problem with that approach is that vendors may be a part of your system for a very long period between sanction-screening. If, in the unlikely event that you have a vendor on the OIG exclusion list or GSA debarment list and they are not screened in a timely fashion, there is some risk of paying severe penalties for that vendor.

      The examples you give of the “snowbirds” are exactly the situations that are very common. I do not recommend sanction-screening physicians who refer patients to the hospital who are not employed by or having staff privileges granted by the hospital. Neither, OIG or CMS call for this to be done and I don’t recommend that this be done. In most cases, the physician will not be known and therefore the specific identifying data will not be easily available. Establishing positive identify to the sanction list ccan be a problem without specific data. Of course, you can check out other databases, such as NPI/UPIN to assist in this effort, but that is a lot of what I would consider unnecessary effort.

      Even if you do get a positive “hit”, there is very little you can do, except withdraw any claim that may have arisen from that referral. You could write a letter to the physician in question, stating that they are on the exclusion list and that they should not send any more patients to the hospital; and, if they do, you will report them to the OIG. Or, you can go ahead and report them to the OIG on the first instance, but you better be sure that you have made positive, verified identification of that individual with the party carried on the sanction list, or run into potential legal difficulties. All in all, I don’t recommend you go beyond for which CMS and OIG have called. You have enough headaches with this process without volunteering for more.

      If you find the entire process burdensome, time consuming, and costly, you may wish to consider “outsourcing” the entire process to a vendor who will do the screening and potential “hit” resolution for you, and provide certified results. Such services exist that likely will cost a fraction of what it takes by using in-house staff; and very little more than using someone’s sanction-screening tool. I suggest you look at complianceresource.com and other vendor sites to compare costs and levels of service.

      Dick Kusserow, former DHHS Inspector General.