Kusserow on Compliance: Tips for determining sanction-screening costs

The majority of HHS Office of Inspector General (OIG) compliance guidance documents are advisory, not mandatory, however there are exceptions. One such exemption is sanction-screening. The OIG makes it clear that it is an obligation to screen employees, physicians, vendors, contractors against the List of Excluded Individuals and Entities (LEIE) and failing to do so could result in all claims and costs associated with that excluded party being viewed as false and fraudulent, which, in turn, could result in significant financial penalties.

This obligation began during my watch as the Inspector General when the OIG developed what is now referred to as the LEIE. CMS requires proper screening as well as enrollment as a condition of payment, mandates that states develop their own sanction databases, and requires enrolled providers to screen against these databases on a monthly basis. Thirty-six states have already moved to establish their own Medicaid sanction list with many now mandating monthly screening against it, as well as the LEIE. All this has increased the burden on compliance officers greatly. It also leads to a lot of questions about best practices. No matter how the compliance officers meet this obligation, proper analysis of the process should be executed. The following are some question and thoughts to consider.

Analytical steps to evaluating sanction-screening

  • Identify those who have personal responsibility for controlling the entire process.
  • List all federal databases that are used to screen (e.g. LEIE, FDA, Excluded Parties List System (EPLS), Drug Enforcement Administration (DEA), etc.).
  • Note the number of state Medicaid databases against which there must be sanction-screening.
  • Determine the proper frequency of screening (e.g. monthly, quarterly, annually, at the time of engagement).
  • Note all of the functions involved in screening efforts (e.g. procurement, compliance office, HRM, medical credentialing).
  • Assess the level of time and effort supporting the sanction-screening program by each function.
  • Compile the time and effort contributed by those involved in the process, including resolving potential “hits.”
  • Identify how sanction-screening reports and documents are maintained.
  • Identity those who sign off on sanction-screening report results.
  • Ensure policies are in place that provide guidance on the entire process.
  • Review how and how long “potential hits” are resolved and by whom.

After conducting the evaluation of the process as it now exists, consideration may be given to alternative and more economical means to accomplish the same or better ends by employing a vendor. There are generally two types of services: (1) paying to use a vendor tool to conduct sanction-screening across multiple databases; and (2) outsourcing the entire process to a vendor.

Today, thousands of health care providers rely on vendor search engine tools to carry out sanction screening in-house. It saves them from developing their own search engine, as well as maintaining and collecting sanction data monthly. If using a vendor tool, the cost should be a fixed rate that can be budgeted; and not one that charges upon a “per click” basis which may prove to be very expensive. Using a vendor tool is only a small part of the sanction-screening burden. The bulk of the screening effort remains for the organization to handle and that effort includes conducting the actual screening, resolving potential “hits,” and preparing a report for the record to evidence it was all done correctly. The alternative may be to “outsource” the entire process to a vendor who will:

  • keep all sanctioned data up to date;
  • continue servicing and improving the search engine technology and capabilities;
  • perform the screening as often as needed (preferably monthly);
  • use its own professionally trained staff to resolve potential hits; and
  • provide a certified report for the record.

The cost to using a vendor tool should be less than what it is costing the organization to do the same work without it. The same hold true for fully outsourcing the sanction screening process; it should be less than what organizations may already be paying to simply access a vendor’s search engine tools. As such, deciding upon a vendor should be a “shopping expedition” to compare services and costs.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.