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Exclusion Monitoring Challenges

May 20, 2021

Building an effective healthcare compliance program that meets legal, ethical, and professional standards requires developing effective processes, policies, and procedures. The OIG exclusion list is one of the sources to monitor to ensure compliance, program integrity, and patient safety. Failing to comply with federal and state regulations could result in fines, loss of federal program reimbursement and eligibility, and even litigation.

Monthly Exclusion Monitoring

In order to be eligible for federal programs including Medicare and Medicaid, CMS requires that all healthcare organizations conduct monthly exclusion monitoring of all employees, contractors, vendors, and ordering and referring providers. To limit Civil Monetary Penalties (CMPs), eligibility and reimbursement delays, and legal consequences, your healthcare institution should regularly screen and monitor all practitioners, employees, contractors, and subcontractors.

According to the Office of the Inspector General (OIG), practitioners, employees, contractors, and subcontractors should be screened against the List of Excluded Individuals and Entities (LEIE) and monitored for exclusions. All employees should also be cross-checked against the General Services Administration’s (GSA) System for Award Management (SAM) and state exclusion lists.

Providers cannot be on any state’s exclusion list, so checking only the states where they are providing care is not enough. Exclusion from one program means exclusion from all federally funded programs. Referring physicians and providers who perform any services reimbursed by a federal healthcare program should be screened, whether under contract or not. This includes all staff as well as those who are involved indirectly with patients such as janitorial, kitchen, and administrative staff. A healthcare institution could have thousands of employees who need to be screened against multiple lists. This can overburden administrative staff, increasing the possibility of lapsed screenings and errors.

In 2020, the average exclusion fine levied against healthcare institutions was $101,000; this does not include losses of time and resources. Due to the high number of mistakes in manual exclusion screening and monitoring, healthcare institutions can use credentials verification organizations with automated screening and real-time monitoring technology to stay compliant.

Challenges of Exclusion Monitoring

Exclusion monitoring doesn’t come without its challenges. Awareness of these challenges is critical to creating an accurate and effective program. Here are the three most common problems with manual exclusion monitoring.

  1. Publicly available data (such as name, address, and specialty) is sparse and inaccurate. Mismatched data or false accusations can cause added problems for your organization. Verified primary data (SSN, Tax ID, or NPI) increases accuracy and should be used in any matching.
  2. According to Performance Standard 8, states are required to report exclusions or terminated providers within 30 days. The reality is that the average time of state-reported OIG LEIE exclusions is 173 days, leaving an average of 4-5 months of lapsed time and risk to your organization.
  3. Lists are constantly updated. However, they are published on different schedules (once a month, once a quarter, and others periodically with no formal schedule). This makes staying up to date difficult. To stay in compliance, checking and cross-checking must be done on an ongoing basis.

Building an Effective Exclusion Monitoring Program 

Failure to stay in compliance comes at a high cost. Whether it happens directly or indirectly, if you or your organization miss exclusions, your institution is responsible for penalties and fines for any care that was given during the period of time when the provider was excluded and you were not yet aware of the exclusion. In order to minimize consequences, your organization should be constantly monitoring your staff and be alerted of any changes.

Building an effective exclusion monitoring program can be a daunting task. However, with reliable exclusion data, automation, and technology, the continuous monitoring of OIG, GSA SAM, and other exclusion lists becomes much less complex. FACIS® (Fraud Abuse Control Information System) is the most trusted data platform of primary source content from federal and state exclusion sources. Our premium data cross-checks thousands of databases, monitors exclusions, sanctions, debarments, and disciplinary actions on an ongoing basis, and alerts you of any changes in status.

A key component to an effective compliance program is using the right automation, tools, and having the most up-to-date provider data. With our gold-standard FACIS®  data set, your organization can ensure the ongoing monitoring of your staff and confidently provide the highest quality of patient care. Verisys’ technology reduces the challenges of manual credentialing and streamlines exclusion screening so that you can focus on your patients.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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