Where to implement exclusion monitoring

Keeping up with medical credentialing and regulations is difficult. At Verisys, we combine our internal expertise with technology. Working with us, or a similar company, can decrease a healthcare organizations’ risk of fines and penalties due to noncompliance and facilitation. 

Many use the end of the year to evaluate current compliance programs. Here is our checklist of what to look for when evaluating exclusion and sanction monitoring programs. 

Let’s level set:  

A compliance program uses effective processes and procedures to define, detect, and prevent legal and state and federal violations in healthcare. Compliance procedures and training programs define and monitor numerous areas for adherence to laws and regulations including patient care, physician license verification, billing, reimbursement, HIPAA privacy, and security.

As acknowledged by OIG Guidance, implementing a compliance program may not completely eliminate improper employee conduct. Nevertheless, compliance programs are vital in defining appropriate conduct, training the organization’s staff, and monitoring adherence to defined policies as they change with updated laws and regulations. 

The effects of allowing an excluded provider to practice are far-reaching and can have severe consequences for your organization. Penalties for individuals on an exclusion list who continues to provide patient care includes (but is not limited to):

• Civil Monetary Penalties of up to $10,000 for each item or service furnished during the time of exclusion
• Lawsuits
• Federal or state program disqualification
• Reputational loss

What Databases Should Your Organization Continuously Monitor: 

In a robust and comprehensive compliance program, databases are continuously monitored for any changes to status’ on exclusion and sanctions.  A single exclusion list does not give a comprehensive view of the provider; there are thousands of provider databases to screen against at both the state and federal level. At the minimum an organization needs to monitor: 

• Office of Inspector General’s List of Excluded Individuals and Entities (LEIE).  
• General Services Administration (GSA)/Systems of Awards Management (SAM) 
• Excluded Parties List System (EPLS)
• National Provider Data Bank (NPDB) 

By monitoring only select data sets, your organization could be unknowingly putting your reputation and your patients at risk by neglecting other data sets that contain vital provider exclusion information.

In addition to federal exclusion lists, states also maintain their own provider exclusion lists. Healthcare organizations should be aware that state Medicaid Exclusion lists are for providers but don’t screen additional staff, entities, and vendors. 

Wondering how someone ends up on a list? 

The LEIE contains two different types of exclusions based upon reported actions: 

• Mandatory exclusions
• permissive exclusions

Mandatory exclusions are imposed for the following reasons:

• Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, CHIP, or other State health care programs
• Patient abuse or neglect
• Felony convictions for other healthcare-related fraud, theft, or other financial misconduct
• Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances

Permissive exclusions are imposed for the following reasons:

• Misdemeanor convictions related to healthcare fraud other than Medicare or a state health program
• Fraud in a program (other than a healthcare program) funded by any federal, state, or local government agency
• Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
• Suspension, revocation, or surrender of a license for failure to provide health care for reasons bearing on professional competence, professional performance, or financial integrity
• Provision of unnecessary or substandard services
• Submission of false or fraudulent claims to a federal health care program
• Engaging in unlawful kickback arrangements
• Defaulting on a health education loan or scholarship obligations
• Control of an entity by a sanctioned individual such as an owner

Interested in learning more about how Verisys can support your program? Contact sales here.