OIG Exclusion & CMS Monitoring

To achieve the goal of 100% compliance, it is essential to understand the importance of OIG exclusion list. As you know, a significant portion of federal tax dollars is used to compensate healthcare providers, whether individual or as a group/company, for their services but, in order to make sure these federal tax dollars are invested in quality and complaint healthcare management systems, the Department of Health and Human Services (HHS) along with the Department of Justice (DOJ), oversee the distribution of these federal tax dollars to healthcare providers and much how these providers are capable to maintain the necessary requirements of quality and compliance.

There are two primary exclusion databases each at state and federal level. They should be reviewed manually and cross-checked alongside as well. These databases have the information of every excluded entity whether individual or a group or company. These databases are OIG Exclusion List Database (LEIE), Medicaid Fraud Control Units (MFCU), General Services Administration (GSA – EPLS) and State Medicaid Exclusion List.

“The federal mandate states, “if you are terminated in one state Medicaid, you are terminated in all states.”

Generally speaking, according to OIG and CMS it is your duty to make a monthly routine check about your employees and vendors. An excluded provider can be charged as high as $10,000 per item claimed per day by CMS when you submit a bill to them. This fine could also include treble damages. Moreover, according to the severity of the non-compliance it possible that you can also incur one or more of these charges:

• Program exclusion of healthcare provider
• Healthcare provider will lose the right to bill CMS for all the related services rendered.
• Additional fines for fake/false/bogus claims under False Claim Act. The fine could go: As high as $11,000 per claim.
• Redo or hold a corporate integrity agreement with OIG.
• Criminal fines and/or subsequent jail time

So, why don’t you avoid the fine and give all such hassles of your OIG and CMS exclusion list to VerifPoint?

VerifPoint will handle all the requirements provided by OIG and CMS. VerifPoint Exclusion services include checking OIG LEIE and SAM to all available state Medicaid exclusion list. Let us handle your monthly checks with our automated systems.

Please make sure to consider your healthcare workforce for possible mandatory and permissive exclusion.

In order to remind you, mandatory exclusions are from a period of 5 to 50 years placed on a healthcare professional because of felony conviction or license revocation due to alcohol/substance abuse, patient abuse, sexual assault or fraud. While, permissive exclusion is for a period of maximum 5 years because of misdemeanor conviction or license revocation due to patient abuse, default on federal student loan, sexual assault, abuse of alcohol or similar substances and/or fraud.

As a responsible, healthcare provider, you should not allocate both the direct and the indirect federal reimbursement for any provision or purchase for any type of goods or services used by any excluded healthcare individual or entity, because they are highly prohibited. This reimbursement also includes any type of salaries, bonuses, benefits or even those items that are claimed or billed by any licensed healthcare provider or administrative personnel.