Ensuring Compliance: Exclusion Screening for Healthcare Employers

Table of Contents

1. Introduction
2. What are Exclusions and How They Affect the Healthcare Industry
3. The Office of Inspector General (OIG) and its List of Excluded Individuals and Entities (LEIE)
4. The System for Award Management (SAM) and its Exclusion Information
5. The Office of Foreign Assets Control (OFAC) and the Terrorist List
6. The Food and Drug Administration (FDA) Disqualification and Debarment List
7. State Medicaid Termination or Exclusion Lists
8. Best Practices for an Effective Exclusion Screening Program
9. Importance of Screening Frequency and Documenting the Process
10. What to do if an Excluded Individual is Found
11. Additional Resources and Tools for Exclusion Screening
12. Conclusion

Exclusion Screening in the Healthcare Industry

In the healthcare industry, exclusion screening plays a vital role in ensuring compliance with regulations and preventing the use of federal health care funds for sanctioned or excluded individuals. Exclusions refer to the process by which individuals or entities are prohibited from participating in or receiving payments from federal health care programs, such as Medicare or Medicaid. This article will explore the importance of exclusion screening, the various sources of exclusion information, and best practices for implementing an effective exclusion screening program.

1. Introduction

Exclusion screening is a crucial component of compliance management in the healthcare industry. It involves checking various databases to verify if an individual or entity is excluded from government-funded healthcare programs. This article will provide an in-depth understanding of exclusion screening and its significance in maintaining compliance.

2. What are Exclusions and How They Affect the Healthcare Industry

Exclusions are imposed by the federal government to prevent sanctioned or excluded individuals and entities from participating in or receiving payment for services funded by federal healthcare programs. The Office of Inspector General (OIG) is tasked with administering exclusions and maintaining the List of Excluded Individuals and Entities (LEIE). This section will Delve into the impact of exclusions on the healthcare industry and the consequences of non-compliance.

3. The Office of Inspector General (OIG) and its List of Excluded Individuals and Entities (LEIE)

The OIG plays a key role in preventing fraud, waste, and abuse in federal healthcare programs. As part of their enforcement efforts, they maintain the LEIE, which contains details of individuals and entities excluded from participating in these programs. This section will provide insights into the OIG's authority, the reasons for exclusions, and the minimum exclusion periods for various offenses.

4. The System for Award Management (SAM) and its Exclusion Information

The System for Award Management (SAM) consolidates various federal procurement systems, including the Excluded Parties List System (EPLS). The SAM includes information on entities debarred, suspended, or excluded from receiving federal contracts or financial assistance. This section will explore the significance of searching the SAM for exclusion information and the challenges associated with verifying matches.

5. The Office of Foreign Assets Control (OFAC) and the Terrorist List

The Office of Foreign Assets Control (OFAC) administers and enforces economic sanction programs to combat terrorism and drug trafficking. They publish a list of individuals and companies known as Specially Designated Nationals (SDNs), with whom U.S. persons are prohibited from conducting business. This section will highlight the importance of checking the OFAC list in exclusion screening and the tools available for searching the list.

6. The Food and Drug Administration (FDA) Disqualification and Debarment List

The Food and Drug Administration (FDA) has the authority to disqualify or debar researchers and professionals involved in clinical testing for non-compliance or misconduct. The FDA maintains a Disqualification and Debarment List, which identifies individuals barred from participating in drug product applications. This section will discuss the significance of screening the FDA list and the challenges associated with verifying matches.

7. State Medicaid Termination or Exclusion Lists

State Medicaid agencies maintain their own termination or exclusion lists, which identify individuals or entities excluded from participating in state Medicaid programs. These lists are essential in preventing excluded individuals from simply moving from one state to another to Continue receiving healthcare funds. This section will emphasize the importance of checking state Medicaid lists and the challenges in maintaining compliance with multiple state requirements.

8. Best Practices for an Effective Exclusion Screening Program

Implementing an effective exclusion screening program requires adherence to best practices. This section will provide guidance on the frequency of screening, the importance of searching name variations, and the significance of unique identifiers in verifying matches. It will also emphasize the need for thorough documentation and dedicated personnel for reviewing name matches and resolving false positives.

9. Importance of Screening Frequency and Documenting the Process

Regular screening is vital to minimize the risk of employing or contracting with excluded individuals. This section will elaborate on the importance of screening frequency, particularly monthly screening of the OIG LEIE, SAM, and state Medicaid lists. It will also emphasize the need for thorough documentation of the screening process to demonstrate compliance in case of audits or investigations.

10. What to do if an Excluded Individual is Found

In the event of identifying an excluded individual or entity, swift action must be taken to rectify the situation and ensure compliance. This section will emphasize the importance of involving legal counsel and considering self-disclosure to the OIG. It will also discuss reporting guidelines and potential penalties for non-compliance.

11. Additional Resources and Tools for Exclusion Screening

numerous tools and resources are available to streamline the exclusion screening process. This section will highlight the resources provided by the OIG, including their Special Advisory Bulletin on effective exclusions. It will also discuss the benefits of utilizing service providers specializing in exclusion screening and navigating the various databases.

12. Conclusion

Exclusion screening is a critical aspect of compliance management in the healthcare industry. By adhering to best practices and utilizing available resources, healthcare organizations can minimize the risk of employing or contracting with excluded individuals. Regular screening, documentation, and collaboration with legal counsel are crucial in ensuring compliance with federal and state exclusion requirements.