The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs on May 8, 2013. This updated guidance is available at https://oig.hhs.gov/exclusions/effects_of_exclusions.asp.
This regulation states that no federal health care program payment may be made for any item or service provided by an excluded person or at the medical direction of an excluded person. Health care entities violating this mandate risk civil monetary penalties of up to $10,000 for each item or service provided by the excluded person. They may also risk an assessment of up to three times the amount claimed, and in serious cases, the health care entity employing or contracting for services with the provider may also face exclusion.
Health care entities, including ASCs, are advised to screen all employees, physicians, allied health professionals, and contractors for exclusion from any federal health care program. The OIG recommends, at a minimum, checking all personnel who provide patient care. Those services are at the greatest risk for civil monetary penalties because they are more likely to be paid for by a federal health care program. The most thorough screening includes services provided to your facility by contract – a pharmacist consultant, sales representatives, administrative and management services, etc.
The OIG does not require monthly screening; however, they strongly encourage completing this task monthly to limit the facility’s liability. Completing monthly screening places your facility in a better position to minimize the potential damages assessed in situations where excluded persons are discovered. Screening should take place when hiring, credentialing, and signing new contracts for services provided to the facility and should continue monthly until termination of employment or contractual arrangement. It also is wise to check state requirements. Many states require or recommend monthly checks of their databases of excluded persons.
You may choose to perform the OIG exclusion review internally via facility personnel or use a third-party vendor. If you use a third-party vendor, keep in mind that it is still the facility’s responsibility to review documentation provided by the vendor. Using a third-party vendor for exclusion verifications does not absolve the facility from liability. Maintain documentation of all searches to verify the process is routinely taking place and serve as a record of the results.
If you discover a prospective or current employee, provider, or contracted person or entity on the exclusion list, you will need to terminate that individual’s employment or contract. You may wish to involve legal representation to assist with the termination and any reporting that needs to be made. If the excluded person provided services to federal health care program patients, payments the facility received from those programs will need to be returned to the federal entities.
Protect your facility from the possibility of civil monetary penalties and fines. Implement a process to complete OIG exclusion checks monthly and maintain records of these reviews on file.
Kelli McMahan, VP of Operations