Healthcare providers, no matter their size, must consider numerous legal and ethical factors when hiring employees and performing services. One of the most important of these is compliance with the Office of the Inspector General’s exclusion guidelines. Here are answers to five of the most common questions regarding exclusion and its effect on healthcare providers:

What Is the OIG Exclusion List?
The OIG exclusion list, called the List of Excluded Individuals/Entities, is a list of people who are prohibited from claiming payment from any federal health programs, including both Medicare and Medicaid. This list is available to healthcare providers, patients and the public. Individuals are typically placed on the list because they have been convicted of Medicare or Medicaid fraud, patient neglect or abuse, or felonies related to patient care and/or the distribution of prescription drugs.

Does Exclusion Prevent an Individual From Being Treated?
It is important to note that being placed on the LEIE precludes a person from being paid through federal health programs for providing services; it does not mean that they are not allowed to be treated through Medicare or Medicaid.

Why Does OIG Healthcare Compliance Matter?
OIG healthcare compliance affects not only individuals, but healthcare providers. This is because, should any provider hire or contract services out to a person on the exclusion list, the federal government can refuse payment and subject the organization in question to monetary penalties. OIG compliance is one of the many reasons over two-thirds (68%) of healthcare providers have internal committees that oversee compliance and ethics. Of these, 41% are led by a chief compliance offer who reports findings and makes recommendations to the committee.

How Can I Screen for Excluded Individuals?
OIG exclusion screening can be conducted using a database provided by the OIG, made easier by supplementary software. However, one of the challenges of screening is that potential matches need to be confirmed (since matches are made based on names, and not social security numbers); some organizations handle investigations internally, while others prefer to contract those services out. OIG exclusion checks should be performed on a regular basis, since new employees are constantly being hired and the list is also being updated.

Is It Possible to Be Removed From the Exclusion List?
After the period of exclusion specified by the OIG, an individual can apply for reinstatement by contacting the Office of the Inspector General and filling out special forms. It’s important to note that reinstatement is not automatic after the exclusion period ends. If reinstatement is approved, the individual is removed from the exclusion list and can be safely hired by healthcare providers.

Do you have any other questions about OIG healthcare compliance? Join the discussion in the comments.

Daybreak Venture, a company providing skilled nurses, has settled charges brought by the Office of the Inspector General that they hired staff that had been excluded from employment with federal health programs, authorities announced.

The OIG’s Office of Audit Services did an investigation that turned up five excluded employees. During the federal investigation, Daybreak Venture revealed they had hired two additional unauthorized employees, according to the announcement.

In March 2014 the OIG initially contacted Daybreak regarding this matter and as a result the company performed it’s own audit covering about 5,000 staffers and entities that are presently or had been linked with Daybreak Venture.

 

The CEO of Daybreak, Michael A. Rich has assured the federal government that since the company discovered these transgressions, they have pledged additional resources and people to work in its Compliance Department to conduct ongoing re-verifications of staff members and entities to prevent those on OIG’s excluded list from employment. He went on to state that the company is fully committed to hiring only those people who are eligible.

Individuals can lose their eligibility to work with federal health programs like Medicaid and Medicare for a number of different reasons, but the most serious would be that they have a criminal record of being convicted of abuse or fraud. Providers are barred from hiring these individuals and then charging the government program for the services provided by them.

 

A Deputy Chief in one of the branches of the Office of the Inspector General says they’ve found that nursing homes tend to employ excluded individuals more than other health care providers. The updated guidelines provide a time period for employers to check the database online that lists all the excluded or unauthorized individuals, entities and organizations.

 

The settlement with Daybreak Venture took effect October 24, 2014.

A provider who employs an excluded individual to provide items or services that are reimbursed by Federal health care program funds will be required to pay back 100% of the funds improperly received and may be subject to liability under the Civil Monetary Penalties Law.
The Bulletins and relevant sections of the SSA should be reviewed by all health care providers who receive funds from Federal health care programs to ensure liability is avoided. Read More Here

The Justice Department is investigating whether several medical labs violated the federal anti-kickback statute. One of them, Health Diagnostic Laboratory Inc. of Richmond, Va., has collected hundreds of millions of dollars from Medicare for advanced blood tests that help predict heart disease. HDL and other cardiac-biomarker labs paid doctors a fee for each sample of blood they sent for testing until a Department of Health and Human Services fraud alert on June 25 cast doubt over the payments’ legality, as a page-one article in The Wall Street Journal reports. Read More at http://tinyurl.com/okjz4e7

What authority does the OIG have to exclude individual or entities? Are there different types of exclusions?

What is OIG’s Administrative Process for Imposing Exclusions?

What is the scope and effect of an exclusion?

Does the LEIE include exclusions from other agencies?

When were exclusions first implemented?

Does an exclusion affect a person’s right to receive benefits under the Medicare, Medicaid and all Federal health care programs?

Does an OIG exclusion affect my ability to participate in a real estate transaction involving Department of Housing and Urban Development (HUD) financing?

What should I do if, when searching the LEIE, I receive a positive match?

What is a waiver?

What is the effect of an exclusion waiver on a payment?

How does an excluded individual or entity get reinstated?

What is the difference between the LEIE and the General Services Administration’s (GSA) Excluded Parties List System (EPLS) and System for Award Management (SAM) websites?

How can I report fraud or abuse related to the Medicare and Medicaid programs?

How do I contact someone about exclusions?

OIG Background Info

The Office of the Inspector General (OIG) in the U.S. Department of Justice (DOJ) is a statutorily created independent entity whose mission is to detect and deter waste, fraud, abuse, and misconduct in DOJ programs and personnel, and to promote economy and efficiency in those programs. The Inspector General, who is appointed by the President subject to Senate confirmation, reports to the Attorney General and Congress. The OIG investigates alleged violations of criminal and civil laws by DOJ employees and also audits and inspects DOJ programs.

The OIG’s nationwide workforce of 420 employees includes auditors, program analysts, criminal investigators, attorneys, and administrative and support personnel. In addition to headquarters’ units in Washington, D.C., and Audit and Investigations Division field offices in Rosslyn, Virginia, the OIG has offices in the following cities: Chicago, Dallas, Houston, El Paso, New York, Trenton, Boston, Philadelphia, Detroit, Atlanta, Miami, Los Angeles, San Francisco, Tucson, and Denver.

Using the Exclusion Database

 

 

07-17-2013
After it self-disclosed conduct to the OIG, North Arkansas Regional Medical Center (NARMC), Arkansas, agreed to pay $395,591.50 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that NARMC improperly billed separately for “incident to” services that were included in its Rural Health Center payment.
07-12-2013
After it self-disclosed conduct to the OIG, Saint Luke’s Health System (SLPS), Missouri, agreed to pay $142,740 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that SLPS improperly billed Medicare and Medicaid for interventional radiology services furnished by a radiology practitioner assistant (RPA) in SLPS’s Radiology Department. Specifically, SLPS separately and improperly billed Medicare for services furnished by an RPA even though, under Medicare rules, payment for services furnished by an RPA in a hospital setting are bundled and paid to the hospital as part of its facility payment.
07-08-2013
After it self-disclosed conduct to the OIG, Sonora Regional Medical Center (SRMC) California, agreed to pay $597,193 for allegedly violating the Civil Monetary Penalties Law. SRMC contracted with a physician to provide professional services at SRMC’s medical oncology outpatient center. The OIG alleged that SRMC submitted claims containing CPT codes 99204, 99205, 99214, and 99215, that it submitted for services provided by the physician that were upcoded and that the physician engaged in a pattern or practice of coding at a higher level that he knew or should have known would result in a greater payment than the code applicable to the services he was actually providing.
06-19-2013
After it self-disclosed conduct to the OIG, Rutherford Hospital, Inc. (Rutherford), North Carolina, agreed to pay $706,090.46 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Rutherford submitted or caused to be submitted claims for physicians’ services provided by a doctor to beneficiaries of Federal health care programs using the provider identification numbers of another doctor, who did not further the services. The OIG contends that Rutherford knowingly misused provider identification numbers, which resulted in improper billing of the claims identified and disclosed by Rutherford.
06-10-2013
After it self-disclosed conduct to the OIG, Mercy Clinic Oklahoma Communities, Inc. (Mercy Clinic), Oklahoma, agreed to pay $51,444.03 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Mercy Clinic employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
05-24-2013
After it self-disclosed conduct to the OIG, Expeditive, LLC (Expeditive), New Jersey, agreed to pay $2,883.53 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Expeditive employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
After it self-disclosed conduct to the OIG, SpecialtyCare Surgical Assist, LLC (SCSA), Florida, agreed to pay $247,024.19 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that SCSA knowingly presented to Medicare, Medicaid, and TRICARE claims for items or services that SCSA knew or should have known were not provided as claimed and were false or fraudulent. Specifically, the OIG contends that SCSA billed the above programs for assistant-at-surgery services provided by certified surgical assistants and registered nurse first assistants, when these programs reimburse such services only if provided by physicians and/or physician assistants.
05-22-2013
Trustees of Tufts College and Tufts University School of Dental Medicine (TUSDM), Massachusetts, agreed to pay $841,120.88 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that TUSDM submitted claims to Medicare for various services from four of their clinics. The OIG contends that these claims were improper because the services were provided by dentists who were not credentialed by Medicare and/or the services or the code level billed were not supported by sufficient medical record documentation.
05-21-2013
Carolyn Murray-Burton, M.D. (Murray), New Jersey, agreed to pay $136,777.59 for allegedly violating the Civil Monetary Penalties Law. The OIG contends that Murray caused her employer to submit claims for reimbursement to Medicaid and Medicaid HMOs for items and services furnished by her while she did not possess a valid medical license.
After it self-disclosed conduct to the OIG, St. Peter’s Hospital of the City of Albany (St. Peter’s), New York, agreed to pay $16,538.70 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that St. Peter’s employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
After it self-disclosed conduct to the OIG, Shahid Mansoor, M.D. doing business as Mansoor Pediatrics (Mansoor), Louisiana, agreed to pay $51,315.90 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Mansoor employed an individual that it knew or should have known was excluded from participation in Federal health care programs.

Baypointe Nursing Home, Inc. d/b/a Baypointe Rehabilitation & Skilled Care Center (Baypointe), Massachusetts, agreed to pay $351,255.44 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Baypointe employed an individual that it knew or should have known was excluded from participation in Federal Health care programs.

The OIG Exclusion Statute states that anyone convicted of crimes relating to Medicare or Medicaid fraud cannot be employed by a healthcare provider. The language in the OIG claims places the burden of verification on the health care facility, with the phrase ‘should have known’ being a major cause for concern with the overriding question being: how can we be sure?

According to sources, “It would take hours upon hours for healthcare facilities to scan available data to find out if any of their employees are excluded, and they’d have to repeat the process every month. It’s a serious cost and labor issue. this ensures total compliance by automatically scanning OIG exclusions, searching their employee roster and finding any exclusions each and every month. Our software does what they simply can’t do.”

Exemption

The application of an OIG exempt individual is that the excluded person shall not be employed,in any capacity, with a doctor that receives payment, indirectly or immediately, from any national medical care program. Simply said if you certainly are a healthcare provider that accepts national bucks, and you have any employees or companies who are on the excluded list, you might face some significant charges — large fees, and perhaps getting on the excluded list yourself.

By law, the healthcare industry has an obligation to verify program exclusion list status of each and every person or entity that they use or with whom they contract.You can find out whether any of your present workers or contractors are on the OIG exclusion lit by planning to the exceptions site of the .gov OIG website. The website has directions on how to check the OIG list.You are likely to ‘periodically’ examine the status of everybody whom you employ or with whom you contract. You also have to check the OIG exclusion status of new workers or companies ahead of bringing them on board.

FYI, it is technically feasible to have a worker who is on the excluded record, nonetheless it would be a hassle from a economic accounting and payment understanding, and legally risky. If you go to the website and discover that one of your employees is on there, it is time to call counsel fast!