Healthcare exclusion monitoring is critical to healthcare compliance because employing or contracting with an excluded provider can result in severe financial penalties, loss of federal program eligibility, and reputational damage. Federal and state exclusion lists identify individuals barred from participating in government-funded healthcare programs, and failure to properly screen and continuously monitor providers puts organizations at significant regulatory risk. This article explains why exclusion monitoring matters and how technology simplifies ongoing screening to reduce administrative burden and maintain compliance.
What Is A Healthcare Exclusion?
A healthcare exclusion is an administrative action taken against an individual or entity by the Department of Health and Human Services (HHS), Office of Inspector General (OIG), or a state Medicaid agency. An exclusion means that an individual or entity is excluded from receiving any money from federal or state healthcare programs. Healthcare exclusions apply to any items or services a provider may furnish, order, or prescribe.
Compliance Requirements for Healthcare Exclusions
In sections 1128 and 1156 of the Social Security Act HHS OIG mandates that healthcare organizations do not hire or do business with “excluded or sanctioned individuals or entities.” The OIG places exclusions into two categories: mandatory and permissive exclusions. If a provider is included on either list it prevents them from being reimbursed by federally-funded healthcare programs.
What is Exclusion Monitoring in Healthcare?
Exclusion monitoring is the continuous monitoring of state and federal exclusion lists to verify that an employee or provider is in good standing. Hiring a provider in violation of exclusion lists may result in fines and civil monetary penalties (CMP) which start at $10,000 per item claimed or service provided by the excluded party. Implementing exclusion monitoring can be difficult because hundreds of lists are constantly being updated. Technology can ease this burden by automatically and continuously monitoring all new providers and current employees for sanctions and/or exclusions.
How Many Exclusion Lists Are There?
The most familiar safeguard for healthcare credentialing departments is the OIG’s List of Excluded Individuals and Entities, which identifies individuals and entities excluded from participation in Medicare, Medicaid, and all other federal healthcare programs. Providers are removed from the list only after reinstatement. In addition to the LEIE, exclusions may also appear on the General Services Administration (GSA) or System for Award Management (SAM) lists.
Most states (42 total) also maintain Medicaid exclusion lists that should be monitored regularly, as reporting delays to HHS OIG can take months. Failing to check state exclusion lists and hiring or retaining an excluded provider places healthcare organizations out of compliance and subject to enforcement actions.
How Verisys Catches Exclusions in Healthcare
Continuously monitoring your staff and providers for exclusions and maintaining compliance can be a daunting task for healthcare administrators. However, with the appropriate technology for your organization, continuous monitoring of all federal and state exclusion lists can be automated.
Verisys offers the most comprehensive data set for screening and monitoring healthcare providers for exclusions and sanctions. With software from FACIS solutions to provider data management, that pulls data from more than 5,000 primary sources, Verisys will verify and monitor your provider’s credentials and notify you of exclusions or adverse actions affecting your staff. As the most trusted and nationally used database for screening and monitoring healthcare providers, Verisys is prepared to keep your patients and your organization safe from excluded providers.
