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The ProviderTrust Blog

Your source for healthcare compliance news, advice from industry experts, and all things related to OIG exclusions.

OIG Exclusion List, Healthcare Compliance, Affordable Care Act, Fraud and Abuse

The ABC's of OIG Exclusion Monitoring

Posted by Mike Rosen on Thu, Dec 17, 2015

The purpose of this blog post is to give a basic understanding of exclusions, industry best practices and a brief description of the federal exclusion databases.

What is an Exclusion?

An exclusion is an administrative action taken against an individual or entity/vendor by the Dept. of Health and Human Services, Office of Inspector General (OIG). The OIG is in charge of enforcing exclusions against individuals or entities. The OIG mandates that health care organizations do not hire or do business with “excluded or sanctioned” individuals or entities/vendors. If an individual or entity/vendor is excluded, he/she/it is prohibited from participating in reimbursements for or from federally funded health care programs (CMS- Medicare, Medicaid). 

Once an individual or entity/vendor is excluded, he/she/it is considered excluded in all states, not just the one excluded in. In other words, under the Affordable Care Act, an individual or entity/vendor excluded in one state, is not permitted to participate in federal healthcare funds in all other states. A person or entity can be excluded by a federal agency (OIG) or by a state Medicaid agency. 

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Healthcare Compliance, OIG, Affordable Care Act, CMS, Fraud and Abuse, Penalties and Fines

Fighting Healthcare Fraud with Fraud Enforcers: ROI is good for DOJ

Posted by Michael Rosen, ESQ on Tue, Dec 01, 2015

Remember what your parents always taught you?  Save now and invest in the future.  Well, for the Department of Justice, investing in fighting fraud in healthcare is big business, and boy is it paying off! 

In March 2015, the DOJ released its findings and report for results of investing in and return on investment for preventing healthcare fraud and abuse. "Administration recovers $7.70 for every dollar spent to fight health care-related fraud and abuse; third-highest on record."  Not bad.

CMS is also adopting a number of preventive measures to combat healthcare fraud and abuse. Provider enrollment is the gateway to billing the Medicare program, and CMS has put critical safeguards in place to make sure only legitimate providers are enrolling in the program.

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OIG Exclusion List, Healthcare Compliance, OIG, Affordable Care Act, Medicaid, Medicare, Fraud and Abuse, Penalties and Fines, Human Resources, Self Disclosure, Sanction Screening, Long Term Care

The Ultimate Guide to OIG Exclusions

Posted by Michael Rosen, ESQ on Tue, Nov 03, 2015

The Ultimate Guide to Exclusions is a one-stop-shop for everything you need to know about OIG exclusions. This all inclusive guide covers the basics of exclusions, the background of the OIG, the fines and penalties surrounding an exclusion and explains the differences between the OIG exclusion databases. It also leaves you, the reader, with healthcare compliance industry best practices and additional resources! 

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OIG Exclusion List, Healthcare Compliance, OIG, Affordable Care Act, CMS

NOTICE: OIG Background Check Requires OIG Exclusion Monthly Monitoring

Posted by Mike Rosen on Thu, Jul 09, 2015

The proper way to screen a healthcare employee or third party vendor includes an initial OIG background check of the List of Excluded Individuals and Entities (LEIE). This should be done prior to the hiring of or commencement of billing for the services or items purchased from a third party vendor.

The question is how often should a healthcare organization check the exclusion list after hire or contracting with a third party.

OIG Background Checks: How Often to Check OIG Exclusion List?

It is industry standard and best practice to conduct a pre-employment background check of the exclusion list.This also meets certain state statutory requirements regulating healthcare.

When an employer combines an background check of the exclusion list with state Medicaid exclusion lists (view full list as of 2-26-2015) as well as license verification, education verification, employment verification, a Social Security number validation, and appropriate criminal records history it can safely rely upon certain protections against negligent hire.  

But after hire, there is a legal doctrine called negligent retention. Which is applied if an employer fails to conduct regular updates to certain public record that can change (such as license verification, criminal record verifications and exclusion background checks). This doctrine also applies to third party contractors and even referring physicians.  

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Industry News, Healthcare Compliance, Affordable Care Act, CMS, Medicaid, Medicare, Fraud and Abuse, Penalties and Fines

New U.S. Attorney General Takes Down Healthcare Fraud-sters

Posted by Mike Rosen on Tue, Jun 30, 2015

Newly appointed Loretta Lynch came out of the box swinging. The HHS OIG and the US Attorney General announced a nationwide "sweep" led by the Medicare Fraud Strike Force in 17 districts. The charges were filed against 243 individuals, which included 48 doctors, nurses and other licensed medical professionals. The crackdown of health care fraud and abuse represents the largest coordinated take-down in healthcare history, both in terms of the number of defendants charged and loss amount. 

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