Navigating Exclusion Lists for Healthcare Compliance

Healthcare institutions must monitor countless lists to stay in compliance; it’s a complex web of regulation. Some lists that should be continuously monitored include federal sources such as the List of Excluded Individuals/Entities (LEIE) (which falls under the Office of the Inspector General (OIG), and the list, which includes a broader set of debarments and exclusions. Additionally, 43 state exclusion lists and Medicaid lists should also be monitored, making screening programs difficult to maintain. Here’s what healthcare providers and institutions need to know about exclusion and debarment lists.

Federal Exclusion Databases to Monitor

The two main federal exclusion databases to monitor include OIG’s LEIE and The General Services Administration (GSA) launched the database in 2012 under a mandate from the Affordable Care Act to compile a broader set of debarred, sanctioned, or excluded individuals or entities. (System for Award Management) includes federal contracting databases such as USDA-FNS, TREAS-OFAC, OPM, HHS, and more.

Launched in the early 1990s, the LEIE “provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other federal health care programs.” This database is downloadable and searchable on OIG’s website.

The LEIE contains two different types of exclusions, mandatory and permissive exclusions. Mandatory exclusions are imposed due to more serious offenses of healthcare fraud, abuse, and neglect, and felony convictions. Permissive exclusions are imposed for misdemeanor convictions, suspension, or revocation of license. This is not an exhaustive list and a more detailed explanation is available.

Which State Exclusion Databases Should Be Monitored? 

Authorized by Title XIX of the Social Security Act, Medicaid was signed into law in 1965 alongside Medicare to provide health coverage to low-income households. Each state administers its own Medicaid program. Although it’s designed to include state exclusion lists, OIG audits show that the LEIE is missing up to 61% of exclusions at the state level. Therefore, in addition to the Federal exclusion databases, healthcare organizations also have an obligation to monitor State Medicaid Exclusion databases (of which there are currently 43) so they don’t miss any information.

Other Databases That Should be Monitored for Fraud and Abuse

In addition to federal and state sources, there are many other databases that should be monitored to prevent fraud and abuse. Some of these include (but are not limited to):

  • SSA DMF: The Social Security Administration’s Death Master File was created in 1980 and records all deaths in the country. The files of death information include the following information from the deceased individual:
    • Social security number
    • First name
    • Surname
    • Date of birth
    • Date of death

    Medicare: On July 30, 1965, President Lyndon B. Johnson signed into law the bill that led to Medicare and Medicaid. Designed to cover healthcare for those 65 years or older and those with disabilities, the Medicare provider list should also be monitored for excluded or sanctioned providers.

    OFAC: The Office of Foreign Assets Control (OFAC) “administers and enforces economic and trade sanctions based on U.S. foreign policy and national security goals against targeted foreign countries, regimes, terrorists, international narcotics traffickers, those engaged in activities related to the proliferation of weapons of mass destruction, and other threats to the national security, foreign policy or economy of the United States.” The OFAC list must also be monitored to ensure that your healthcare organization is not unknowingly doing business or employing individuals or entities that may be engaging in terrorism or narcotics trafficking activity.

How to Monitor All the Federal and State Lists

Data can be an ally in fighting fraud and abuse. However, premium technology is required to optimize the large volumes of provider data available to healthcare organizations. There are thousands of records that should be continuously monitored. The right technology can scan provider exclusion data on an ongoing basis and alert your organization if one of your providers, employees, vendors, or contractors appears on any of the lists. Verisys’ technology provides transparency and integrity using over 320 million verified, validated, and authenticated records that can help you screen your population and build your compliance program with confidence. With in-depth screening, monitoring, and alerts, your healthcare organization can be confident that it remains in compliance with federal and state regulations and industry best practices for patient safety.

Verisys Written by Verisys
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