Provider Sanctions And Sanction Monitoring Best Practices

Did you know within an average population of medical professionals, 2-5% of individuals are on a provider sanction list? A medical sanction is detrimental to the excluded individual and the affiliated entity. Employing an individual will jeopardize a healthcare provider’s ability to continue federal programs. In short, an entity will lose the ability to service patients or members with Medicare or Medicaid insurance. A heavy fine follows based on the length and engagement. Civil Monetary Penalties (CMPs) can be up to $10,000 for each item or service the excluded person provides or an assessment of up to three times the amount claimed.

Knowingly or unknowingly employing this individual will lead to large fines and a tarnished reputation. An extreme example is Dr. Death, but identifying a sanction is common. You can track sanctions and other healthcare fines from the OIG here.

While sanctions lists are constantly evolving and expanding, compliance with Health and Human Services (HHS) Office of Inspector General (OIG) standards are becoming more stringent. This means that ensuring effective and regular screenings is more complex than ever.

Step 1: Screen all employees, providers, and entities:

Verisys today works with pharmacies, health plans, hospitals, and background screeners to identify physician sanctions. An effective compliance program should screen and verify both employees and entities before engaging in business. Imagine when you applied for a job–often, there may be information we want to withhold (living in Boston, I may have some parking tickets), but this is magnified when dealing with patient health.

A comprehensive program will not only review the National Practitioner Data Bank (NPDB) and look across other federal and state sources like OIG, SAM, DEA, and DMF (to name just a few) for a complete picture. An initial screen will flag many bad actors and entities. Some flagged may not intentionally hide information (missed student loan payments) but having the total picture will drive informed hiring and network decisions. Employers should go back as far as they can to understand the behavior.

Step 2: Continuous Monitoring:

The OIG’s administrative process for imposing exclusions may take up to 18 months. A monthly provider sanction monitoring and comprehensive CMS exclusion monitoring are advised. Effective sanction screenings check both federal and state databases, are automated for regular and ongoing updates, and will capture any paper trails of questionable behavior often missed by traditional background checks. When screening against complete data sets, automated alerts can be generated before the sanction is even issued, allowing parties to take action, such as making appeals to the Department of Health and Human Services.

Verisys Plug:

Verisys FACIS (Fraud Abuse Control Information System) delivers 360-degree transparency on providers, staff, and entities for the organizations who hire, credential, refer and reimburse for healthcare delivery, such as retail pharmacies, telemedicine, staffing companies, health systems, payers, and pharmaceutical companies.
FACIS is the industry’s most comprehensive database consisting of primary content from federal and state sources for exclusions, sanctions, debarments, disciplinary actions, and adverse events against healthcare professionals and entities for all 868 taxonomies and all 56 U.S. states and jurisdictions. By contrast, other credentials verification organizations (CVO) limit their searches by license type or to one or a few states. With FACIS you get current and historical records nationwide for individuals and entities.