Importance of Checking Exclusions

Checking exclusions is a key component of any viable compliance program. The Office of the Inspector General (OIG) of the US Department of Health and Human Services maintains a list of excluded individuals and entities (LEIE). Anyone who hires an individual or entity named on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, health care entities need to routinely check the LEIE to ensure that new hires and current employees are not on the excluded list. At a very minimum all rehab programs should have exclusions checks as part of their annual monitoring and auditing program. This is in addition to any license checks and verifications that are currently being conducted as part of employment processing or annual review.

The effects of an exclusion are outlined in the Updated Special Advisory Bulletin on the Effect of Exclusions From Participation in Federal Health Programs, however, the bottom line is that “no payment will be provided for any items or services furnished, ordered, or prescribed by an excluded individual or entity.” Keep in mind that this is not only Medicare, but Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States. A frequent questions, is “how often should I screen?” According to the Special Advisory Bulletin:

To avoid potential CMP liability, providers should check the LEIE prior to employing or contracting with persons and periodically check the LEIE to determine the exclusion status of current employees and contractors. Providers are not required by statute or regulation to check the LEIE. The LEIE is a tool that OIG has made available to providers to enable them to identify potential and current employees or contractors that are excluded by OIG. Because there is no statutory or regulatory requirement to check the LEIE, providers may decide how frequently to check the LEIE. OIG updates the LEIE monthly, so screening employees and contractors each month best minimizes potential overpayment and CMP liability. ……. In 2011, CMS issued final regulations mandating States to screen all enrolled Medicaid providers monthly.

Importance of Checking Exclusions for Your Practice or Department

Exclusions from Medicare may be checked very easily via the OIG exclusions online database inquiry tool. Up to 5 employees or entities may be checked at any time, so for small practices this is ideal. For larger practices and hospitals, the entire database can be downloaded monthly (as it is updated), and a query may be run to check current employees against the OIG database for excluded employees. Additionally there are third party service that provide routine exclusion checks for not only the OIG but for Medicaid as well. Many state Medicaid programs upload their exclusions to the OIG database, however, if you provide Medicaid therapy services, you are required to check the Medicaid exclusions on a monthly basis per CMS regulations.

What are the effects of hiring an excluded employee? Will first off, you will have to pay back the appropriate federal healthcare program for services (read the above advisory for all the rules), but what is sobering are the fines – the civil monetary penalties which multiply faster than love bugs in May in Florida.

Per the OIG,

an excluded person that submits a claim for payment to a Federal health care program, or causes such a claim to be submitted, may be subject to a CMP of $10,000 for each claimed item or service furnished during the period that the person was excluded. The person may also be subject to an assessment of up to three times the amount claimed for each item or service. In addition, violation of an exclusion is grounds for OIG to deny reinstatement to Federal health care programs.

An excluded individual or entity that knowingly conceals, may also be subject to criminal prosecution. The stakes are pretty high! Rehab Compliance Newsletter subscribers were offered a Compliance Monitoring and Auditing Tool for free download in last month – nearly 50% of subscribers downloaded this tool. This tool included licensing verification as well as checking exclusions and sanctions. If you haven’t subscribed yet, please do so as our next compliance tool that will be offered is the Red Envelope Policy for when the auditor or investigator knocks at your door.

Do you do routine exclusions checks at the OIG website? Do you document the results to the file? Do you accept Medicaid patients? Do you check the Medicaid exclusions list on a monthly basis as CMS requires?

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Nancy Beckley

Nancy J. Beckley is the president of Nancy Beckley & Associates LLC, a firm specializing in outpatient therapy compliance. The firm offers compliance outsourcing, risk assessment, compliance plan development, annual compliance training, and external auditing, due diligence and investigation support. Clients include providers under Medicare probe review, progressive corrective action plans, corporate integrity agreements, ZPIC investigations and RAC audits.

Nancy’s background includes 15 years hospital experience serving in management capacities at two large inpatient rehabilitation facilities with extensive managed care contracting and program management expertise. A therapist by background and training, Nancy has served as program director, facility director and administrator in both inpatient and outpatient rehabilitation facilities.

She is a nationally known speaker in the area of rehab compliance, and has presented at the Provider Practice Compliance Conference, Florida Compliance Conference, and the Healthcare Compliance Association Compliance Institute. She was featured in a Healthcare Compliance Association webinar on Hospital Risks in Outpatient Therapy, and has authored three articles for Compliance Today and written over 20 articles on the RAC program.

Ms. Beckley’s area of expertise includes:

• Compliance program development, consulting, training, and external auditor

• Medicare regulatory requirements for outpatient therapy providers, including extensive experience in Medicare survey and certification for outpatient therapy providers

• Audit and consulting engagements under attorney-client privilege for risk assessment and potential payback liability analysis

• Medicare program integrity initiatives: MACs, RACs, CERT, ZPIC, probe reviews, pre and post payment reviews

• Nationally recognized expert on CORFs, served on the Medicare CORF Technical Expert Panel

• Hospital outpatient compliance consulting, auditing & training

• Compliance due diligence activities in acquisition and portfolio development to assess Medicare compliance risk

EDUCATION: University of South Florida, M.B.A.; Harvard University School of Public Health Course for Managed Care Executives; University of Illinois, M.S.; University of Wisconsin, B.S.

PROFESSIONAL ASSOCIATIONS: Board of Directors, National Association of Rehab Agencies (NARA); Member, Healthcare Compliance Association; Senior Contributing Editor, RAC Monitor + Monitor Mondays; Compliance Columnist for APTA’s IMPACT Journal

PROFESSIONALCERTIFICATIONS: CHC, Certified, Healthcare Compliance by the Healthcare Compliance Certification Board

PUBLICATIONS & PRESENTATIONS: Available upon request

CONTACT: 414-748-4376; [email protected];