Exclusion and License Screening – Not an Option

April 28, 2015

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OIG Guidelines Clarification (May 2013)

• Providers, contractors, and employees need to be checked prior to employment or contracting, then monthly for: – Exclusions – Licenses (if applicable)

• If excluded from any federal agency program, then party is excluded from ALL government health care programs (Medicare, Medicaid, CHIP, Tricare, Veterans programs)

• Who is “accountable”? Anyone “who knows, or should know” of the exclusion, yet allows the excluded person/entity to deliver services and get paid with any Government monies

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Who Should be Screened for Exclusions?

• Per OIG: any employee (including leadership), practitioner, contractor, or entity paid with money obtained from a Federal health care program, either directly or indirectly, or in whole or in part

• Exception: “if payment is from funds separated from any Government monies” – virtually no health care organizations have segregated accounting systems and therefore do not qualify for exception

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Potential Consequences of Employing an Excluded Person/Entity

• Payments stopped or suspended• Civil Monetary Penalties (CMPs)

– $10,000 per each claimed product and service, plus treble damages (3 times the cost of the product and service)– One excluded provider quickly results into $-millions!

• “False claims” liability• Debarment• Incarceration

Similar potential consequences apply for employing an unlicensed person/entity; though CMPs vary based on the severity of the situation (unlicensed, revoked/suspended license…), they can be in the same range as for employing an excluded person/entity.

Primary Sources to Check Exclusions

OIG recommends that screening be performed through the List of Excluded Individuals and Entities (LEIE):

• Maintained by OIG• Updated monthly• Provides more details about basis for exclusion than GSA’s SAM• OIG staff can respond to questions and requests for verifications

Best practice is to check LEIE, System for Award Management (SAM), and all Medicaid exclusion lists from currently-reporting states (to mitigate timing of reporting from State to Federal)

(OIG Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, May 8, 2013; http://oig.hhs.gov/exclusions/files/sab-05092013.pdf)

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Checking on Licensure

OIG: “We require that Medicare contractors review State licensure board data on a monthly basis to determine if providers and suppliers remain in compliance with State licensure requirements.”

(Federal Register, Vol. 76, No. 22, February 2, 2011, Pp. 5865-5866.)

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What is FACIS?

• Sanctions, Exclusions, Debarments, and Disciplinary Actions • All

– Providers, Persons and Entities– All Provider Types– All Reporting Jurisdictions

• Current and Historical• Primary Source Data only

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• Includes 139 federal sources, 120 state sources– Federal level data plus state Medicaid sanctions (35 states), 42

HEAT sources, 51 AG Notice and Release sources and state level procurement/contractor debarment sources

– OIG, SAM, DEA, FDA, PHS, ORI, TRICARE and OFAC SDN data ‐(federal only) and Medicare Opt-Out

Level 1M

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• All sources included in FACIS 1M, plus– Data available from all publishing jurisdictions in the United

States from all disciplinary and licensing boards including all professionals within those jurisdictions

– Includes the District of Columbia– Includes all provider types (not just MDs and DOs)

Level 3

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