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Exclusion Monitoring – Why It Is So Important to Healthcare Compliance?

February 24, 2021

A practicing healthcare provider with an exclusion can have serious consequences for healthcare organizations. Navigating federal and state exclusion lists can be a confusing and daunting task. This article will help you better understand healthcare exclusion lists and how to leverage technology to relieve the administrative burdens of screening and monitoring your providers to maintain regulatory 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 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? 

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. Navigating this process 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?

There are two federal exclusion lists and over 40 state exclusion lists that should be continuously monitored for updates and changes. Checking each of these sources for all of your providers on an ongoing basis can be time-consuming and overwhelming. Failure to check each of these exclusion lists regularly can put your organization at risk for fines and penalties

The most familiar safeguard for healthcare credentialing departments is the OIG’s List of Excluded Individuals and Entities. The LEIE “provides information to the healthcare industry, patients, and public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal healthcare programs.” Individuals and entities are removed from this list once they have been reinstated. In addition to being debarred or sanctioned on the LEIE, an individual or entity may be debarred or sanctioned 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 exclusions or terminated Medicaid providers to HHS OIG may take several months. If you fail to check state exclusion lists and hire or retain an excluded provider, your healthcare institution will not be in compliance and will be subject to fines and penalties.

How Verisys Catches Exclusions 

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 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.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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