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New Jersey Provider Exclusion Screening

August 13, 2020

To guard against fraud and abuse and keep patients and healthcare entities safe, the federal government maintains a database of medical providers who have been convicted of fraud and are excluded from participation in government-funded healthcare programs. This database, called the List of Excluded Individuals and Entities (LEIE), can be found on the website of the Office of the Inspector General (OIG). Healthcare entities are expected to check providers against this list routinely and whenever they hire a new provider. Entities who don’t routinely check the list could unknowingly hire or employ an excluded provider.

If healthcare entities bill the government for services provided by a medical professional on the LEIE, they won’t receive reimbursement for those services. Healthcare entities can also expect severe penalties for hiring or employing an excluded provider, even if the entity was not aware the provider was on the list. Healthcare practices should prioritize thorough and ongoing screenings against the OIG exclusion list.

State governments maintain similar databases. Although state and federal agencies share the information on the lists, healthcare entities shouldn’t assume that checking just one list is sufficient since time may lapse before new information is entered. You should check both state and federal exclusion lists regularly.

What Are the New Jersey Exclusion Screening Requirements?

The State of New Jersey Medicaid Fraud Division maintains the NJ Debarment List. The list is updated monthly. Healthcare entities in New Jersey are expected to check the list regularly.

If you find a potential match, you should next verify that the person on the list is indeed the individual provider you are verifying. If you are uncertain, you can fill out an Exclusions Verification Form and email it to the Office of the State Comptroller. Once you’ve sent the form, you’ll receive an email detailing next steps.

Why Are Some Providers Excluded from Government-funded Healthcare Programs?

Once a provider’s name is placed on the LEIE, the government can refuse to make any type of payment for any type of service, even those that don’t deal directly with patient care, such as vendors and drivers. Providers on the list have been convicted of some type of crime or misdemeanor that relates to Medicaid or Medicare. These can include:

  • Medicare, Medicaid or other healthcare fraud
  • Patient abuse and neglect
  • Financial misconduct
  • Healthcare-related theft
  • Illegal prescription, dispensation or distribution of controlled substances
  • License revocation or suspension
  • Submission of false claims
  • Unlawful kickbacks
  • Providing unnecessary or substandard care
  • Defaulting on healthcare education loans
  • Administration of a sanctioned healthcare entity

By using these criteria to exclude providers from practice, state and federal governments protect patients and health care entities from medical and financial harm.

How Can Healthcare Entities Avoid Hiring an Excluded Provider?

Although consistent screening against state and federal exclusion lists can take a lot of time, it’s important to make sure they are done frequently since provider verification is required to stay in compliance with state and federal regulations. With some organization, you can ensure the process runs smoothly. One solution is to implement a compliance program.

The New Jersey government does not require healthcare entities to use compliance programs, however, compliance programs can help keep your practice organized, responsible, accountable, legally compliant, and most importantly keep your patients safe. The larger your organization, the more important it becomes to safeguard your practice and your patients. Successful compliance programs will address fraud and abuse avoidance, billing integrity, quality of patient care, provider verification, credentialing and privileging, and other aspects of healthcare compliance law.

No matter what system you choose, provider credentialing is not only legally required, but also essential, to keep you and your patients safe.

FACIS® by Verisys makes it easy for you to verify provider credentials not only against the OIG and State Exclusion databases but also against thousands of other primary sources with real-time results for every single transaction. Verisys performs identity verifications with due diligence on all possible matches identified through the exclusion screening process in order to determine true and correct matches with over 99.5% accuracy. Learn more from Verisys about how you can ensure your providers’ credentials meet all government and regulatory standards.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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