Best Practices in Healthcare Sanctions Monitoring

Employers in the healthcare field are subject to a myriad of compliance regulations, including ensuring workers remain in good standing with federal and state laws regulating federal and state healthcare funding. The Office of the Inspector General (OIG) has the authority to exclude individuals and entities from federally funded health care programs pursuant to § 1128 of the Social Security Act. Additionally, the OIG has exclusion authority in Medicare and State health care programs under § 1156 of the Social Security Act. A list is maintained of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Civil monetary penalties may be imposed on any organization or person who employs an individual or entity on the LEIE.  

There are numerous reasons why an exclusion may be imposed. Mandatory exclusions require the OIG to exclude an individual or entity from participation in all federally funded healthcare programs when there is a criminal conviction for Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances. Under permissive exclusions, the OIG has discretion to exclude an individual or entity for a variety of reasons including misdemeanor convictions related to health care fraud other than Medicare or a State health program, fraud in a program (other than a health care 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 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 health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee. 

To avoid civil monetary penalties and associated organizational risk, healthcare providers should conduct a search of the LEIE pre-hire and throughout employment for any workers engaged in providing federally funded healthcare services. The effect of an OIG exclusion is that no federal health care program payment may be made for any items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person. OIG oversight extends to all individuals working in or providing services to a facility receiving federally funded payments for services, including but not limited to those furnishing administrative and management services, billing services, transportation services, serving in executive or leadership roles, and technology support. While the OIG does not define specific timelines for periodic searches for current workers, the generally recognized standard to effectively manage risk is to conduct a search, at minimum, on a monthly basis. 

Conducting individual searches of large worker populations can be an arduous and time-consuming task for compliance, risk mitigation, and human resource professionals. Fortunately, recent advances in technology now afford automated periodic and continuous monitoring of the LEIE, other key federal and state exclusions and debarment lists, state abuse registries, and state licensing boards. Products like AccuSourceHR™ Workforce Solutions' SanctionsSource™ Continuous Healthcare Sanctions Monitoring afford organizations the option to conduct Level 1 monitoring (federal lists and databases) or Level 3 monitoring (federal and state lists and databases plus state licensing databases) with ease. Workers requiring monitoring are simply uploaded onto the consumer reporting agency (CRA) platform. As new employees and contractors are onboarded or existing staff is termed, organization system users add or delete them from the managed pool. If a current pool member is the subject of sanction or debarment action on one of the monitored lists/databases, the healthcare client is notified of the change of status to ensure they can take immediate action to protect their organization. State license monitoring is often also available on Level 3 monitoring services.  

Periodic and continuous healthcare sanctions and debarment monitoring programs frequently are more cost-efficient and provide greater overall value than conducting individual periodic LEIE and/or state debarment and sanctions searches. Program management labor is often minimized as employers only need to manage notifications for individuals incurring sanctions, debarment, or license suspensions/revocations versus the need to review individual search results for all workers subject to screening, Additional many products on the market today also include other risk mitigation databases including the Office of Foreign Assets Control- OFAC (terrorist watch list) and other healthcare-related compliance databases like the Drug Enforcement Agency (DEA) and the Food and Drug Administration (FDA) watchlists.     

Want to learn more about how AccuSourceHR™ Workforce Solutions makes healthcare sanctions screening easier? Contact us today at marketing@accusourcehr.com.