The special bulletin mentioned previously provides guidance for organizations that would like to hire or employ providers who are on the exclusion list. Essentially, so long as a provider does not render services or items to a federal health care program and the funds do not overlap, they can be employed without being subject to CMPs. This can be a tricky landscape to navigate, so special precautions should be taken when working with excluded entities and providers.
According to the OIG :. An individual or entity excluded under sections a 1 , a 3 or a 4 of the Act may be eligible for a waiver only when the excluded individual or entity is the sole community physician or the sole source of essential specialized services in a community AND the exclusion would impose a hardship on beneficiaries as defined in section A i 5 of the Act of that program. An individual or entity excluded under section a 2 of the Act as a result of a conviction related to patient abuse or neglect is not eligible for a waiver.
See 42 CFR Only an administrator of a federal health care program can request a waiver. A provider or entity cannot request a waiver for themselves.
The OIG also lists the waivers currently in force as well as a letter outlining the scope for the waivers on their website. Employing or contracting with an individual or entity on the LEIE can hold serious risks — in both money and reputation — for an organization and the patients they serve. Verisys offers the most comprehensive data set for screening and monitoring health care providers with continuous updates.
With one login, an organization can automate continuous monitoring and set alerts to receive notice of adverse action affecting one of your providers. And while the OIG exclusion list is important, it is not a comprehensive solution to searching for fraudulent, abusive, and risky providers.
Verisys checks thousands of additional data sources to protect your organization from financial and reputational risk and increase patient safety. Patients however are at potentially at risk of receiving services from ethically questionable healthcare practitioners or providers. Therefore, the monthly check of employees, contractors, and vendors against the current LEIE must not be limited to healthcare professionals primarily concerned with patient care.
This review process should also include employees providing support services as well as administrative staff and managers. It does not matter if they do not have any interaction with the patients. If such excluded individuals are connected to your business which is participating in federal or state healthcare programs, you will be in violation of the law every time they carry out their functions in relation to your business.
Reinstatement is not automatic. Per the OIG, to participate in Medicare, Medicaid, and all other Federal health care programs once the term of exclusion ends, the individual or entity must apply for reinstatement and receive written notice from OIG that reinstatement has been granted. There are resources available to help plans and providers to better understand and conduct screening themselves.
They can look to the Compliance Resource Portal maintained by the OIG for helpful information about federal fraud, waste and abuse laws as well as trainings and tools related to compliance program effectiveness and understanding program exclusions. Before you decide to take on this screening work with your own staff, consider the complexity and risk factors. For example, a name on the LEIE may be similar to that of provider but differs enough to rule out a clean match.
These require further work and investigation to resolve ambiguities which can be very time consuming. Data submitted by state fraud units are incorporated promptly upon receipt. However, even though states are required to submit their exclusion data monthly to the OIG, submission delays are frequent. This lag time, often several months, impacts the currency of data in the LEIE. Therefore if provider organizations decide to forego checking against state exclusion lists and instead rely solely on the LEIE which should include all up to date state exclusions submitted by state agencies and fraud units they risk not monitoring against the most up to date sources available.
The OIG can hold providers accountable and impose fines if an excluded individual or entity is allowed to provide services or supplies after they appear on the LEIE. That is a conservative estimate. Violations have resulted in fines of millions of dollars on many occasions.
For the reasons states above, regularly monitoring against the LEIE as well as the other required lists can be a daunting process that can leave your organization vulnerable to reimbursement and staffing problems. From a business perspective, contracting with an organization that specializes in exclusion screening, like Streamline Verify, supports both contract compliance and avoidance of potentially significant fines.
In addition, having this monthly process performed by an organization that specializes in the review process can save the time of your staff resources and eliminate the worry over potential fines lurking in updated LEIE each month. There is a simpler solution, however. Streamline Verify can perform searches across all available databases at both the state and federal levels to assure that any matches or potential matches are identified and verified.
They offer a turnkey screening process that can efficiently screen all of your employees, contractors and potential hires with just one click. There are Medicare specific lists as well as state Medicaid lists that should be checked as well. Here are a couple of eye-openers from the experience: There's a lot to learn.
Compliance law is constantly changing. As begins, here are five things that you can do to tighten up compliance at your facility. Every month.
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