The Office of Inspector General (OIG) regularly lists licensed healthcare professionals as ineligible to practice medicine. When an employee shows up on the OIG Exclusion list, you may not be able to bill for their services and you may be fined if he or she continues to practice. What are you doing to verify that none of your employees are excluded?
According to the Officer of Inspector General, an exclusion means “that no payment will be made by any Federal health care program for any items or services furnished, ordered or prescribed by an excluded individual or entity. No program payment will be made for anything that an excluded person furnishes, orders, or prescribes.”
This includes both Medicaid and Medicare and applies to the employer:
“This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, any hospital or other provider for which the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person.”
This would represent a major monetary loss for your organization. Not only could your Medicaid and Medicare benefits cease, but you could also be subject to additional fees and penalties. It is recommended that each employer checks OIG exclusion lists at least once per month.
Read more from the OIG on exclusions here: “Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs.”
How does an individual become excluded?
Practitioners are excluded if they have been convicted of a patient abuse crime or has violated the Medicare/Medicaid billing rules. Just about anybody can be excluded – physicians, nurses, technicians, pharmacists, physical therapists, occupational therapists and even some unlicensed individuals can be excluded.
When the OIG considers excluding an individual, they first send a Notice of Intent to Exclude letter. The OIG will then carefully consider any material provided by the individual before making a final decision. The decision can be appealed.
Every month the OIG publishes an updated list of Excluded Individuals that cannot participate in federal health care programs including Medicare and Medicaid. If one of your employees show up on this list, you should suspend or terminate the individual immediately and stop billing government payers for their services. You will want to consult your legal team and discover if you have already billed for services performed after the exclusion.
To prevent issues with OIG Exclusions, consider a software system that can immediately alert you if one of your employees shows up on the list. EverCheck verifies and monitors your employee roster against the OIG list of Excluded Individuals and Entities. If there are any issues, all appropriate managers will receive an email notification.
The OIG suggests that providers maintain documentation of all searches performed in order to verify the results of potential name matches. EverCheck will also capture and automatically update your OIG history report.