BLOG: Health care regulatory 101: Exclusion screening
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Key takeaways:
- Practices should conduct exclusion screening on all employees, owners, contractors and vendors.
- Screening will identify those not able to participate in federal or state health care programs.
As a part of a comprehensive health care compliance program, every medical practice should conduct regular exclusion screening.
What is exclusion?
The Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services is responsible for enforcing federal fraud and abuse laws as they relate to the federal health care programs (FHCPs), including Medicare and Medicaid. As part of that enforcement power, OIG has the authority to exclude individuals and entities from participating in these programs in situations where they have violated certain laws or were considered a threat to beneficiaries or the program funds. If an individual or entity has been excluded by OIG, payment from FHCPs is prohibited for anything that the excluded individual or entity furnishes, orders, prescribes, administers or manages. Importantly for medical practices, this means that the practice may not seek reimbursement from FHCPs for a service where an excluded individual participated in any way. For example, an ophthalmology practice cannot submit a claim for an OCT where the technical component was performed by a technician who is excluded by OIG. The reach of the payment prohibition would be far more expansive — and detrimental to the practice — if the excluded individual were, for example, the administrator who manages the practice’s operations.
As a part of a comprehensive health care compliance program, every medical practice should conduct regular exclusion screening.
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What is exclusion screening?
Exclusion screening is the process of verifying that a practice’s vendor, contractor, or current or potential employee is not prohibited from participating in federal or state health care programs like Medicare and Medicaid.
Who should be screened?
Practices should screen all employees, owners (both direct and indirect), independent contractors and vendors.
When should I conduct exclusion screening?
Screening must be conducted when the individual or entity first becomes affiliated with the practice (for example, when a new employee or independent contractor is hired, when a new contract is signed with a vendor, or when a new person becomes a direct or indirect owner of the practice). Thereafter, screening should be completed at least monthly. In fact, some payor contracts require practices to conduct monthly screening checks as the OIG exclusion database is updated monthly.
If you are pursuing a sale of your practice, the buyer will likely expect the practice owners to make representations in the purchase agreement that the practice regularly conducts exclusion screenings and that none of the practice’s employees, owners, independent contractors or vendors are excluded. Additionally, the buyer will almost certainly conduct confirmatory exclusion screenings as part of its diligence process, and you do not want to be surprised by the results.
How do I perform an exclusion screening?
The OIG maintains a public database of excluded individuals and entities. Performing an exclusion screening is simply a matter of searching this database for the name of the individual or entity affiliated with your practice. Exclusion screening software or outside vendors can help to perform regular exclusion screenings depending on your practice’s needs. The OIG’s database is known as the List of Excluded Individuals and Entities (LEIE), and it can be searched online or downloaded as a data file.
In addition to searching the LEIE, practices should also search the SAM database, maintained by the General Services Administration, to identify parties excluded from receiving federal contracts, certain subcontracts, and certain types of federal financial and non-financial assistance and benefits. Each state also maintains a separate list of individuals or entities that have been sanctioned by that state’s Medicaid program. Practices should search the database applicable to their state’s Medicaid program as well as the state’s Medicaid exclusion database for any state in which the practice knows the individual or entity has offered health care services or products.
What should I do if my screening reveals a hit?
First, be sure to verify that your search revealed the correct individual or entity by conducting a second level search using a social security number or tax identification, which has more specificity. If after verifying that an individual name listed in the database is in fact the person or entity you were searching, it is advisable to seek guidance from a health care attorney with experience in dealing with excluded parties.
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