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Protect Patients from Incompetent or Excluded Practitioners

November 13, 2020

With an influx of changes to medical credentialing and regulations, there is also increased risk for healthcare organizations to stay in compliance. A compliance program that leverages the right technology alongside the appropriate strategy can decrease healthcare organizations’ risk of fines and penalties due to noncompliance and facilitate the highest level of patient care. Here’s what to know about compliance programs in today’s medical environment.

Why Should A Comprehensive Compliance Program Be an Integral Part of Your Organization? 

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.

A compliance program is crucial for every healthcare organization and provider and is an ongoing process. In today’s shifting medical environment, a compliance program is even more important to keep your medical staff educated and in compliance. Organizations should regularly review and update policies and procedures to ensure adherence to changing healthcare laws, regulations, and professional standards.

What Databases Should Your Organization Continuously Monitor? 

In a robust and comprehensive compliance program, databases are continuously monitored for any changes.  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 federal level, exclusions can be found on the Office of Inspector General’s List of Excluded Individuals and Entities (LEIE).  The General Services Administration (GSA)/Systems of Awards Management (SAM), the federal entity that excludes companies and individuals from federal contracts, includes the Excluded Parties List System (EPLS) which includes exclusion records from a variety of industries. Independently curated lists such as the National Provider Data Bank (NPDB) contain information on adverse actions against practitioners that contribute to physician license verification but are not comprehensive. 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. Additionally, many of these lists may lag behind reported incidents, especially during COVID-19.

How Does a Provider Get on An Exclusion List? 

The LEIE contains two different types of exclusions based upon reported actions. Classified as 1) mandatory provexclusions and 2) permissive exclusions, these categories distinguish the acts that determine the disciplinary action. Providers will be added to exclusion lists based on the infractions you see below. Keep in mind that these reasons are not exhaustive.

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

How Verisys Can Help Support Your Compliance Program

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

Despite increased pressure on medical organizations due to COVID-19, comprehensive provider screening cannot be compromised. In order to protect your organization and your patients, all federal and state exclusion lists should be cross-checked and monitored continually to reflect accurate and timely provider data.

The best way to continuously monitor without increasing administrative burden is to integrate provider credentialing services with premium trusted technology into your compliance program. With automated technology, all providers, staff, entities, vendors, and owners are continuously monitored against all federal and state exclusion lists for exclusions, sanctions, debarments, and disciplinary actions.

Verisys provides continuous screening, license verifications, and monitoring of healthcare providers with comprehensive and accurate data sets. Verisys is the most trusted provider in credentialing services and healthcare provider credentialing with 99.9% accuracy in physician identity verification.

Our commitment to accurate and comprehensive provider exclusion data monitoring allows your organization to mitigate risk, increase trust, and improve the quality of healthcare. Contact Verisys to integrate our gold-standard FACIS technology into your compliance program because the world needs confidence in our healthcare organizations right now more than ever.

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