As the healthcare industry increasingly adopts telehealth to deliver care, healthcare providers must remain vigilant in ensuring compliance with exclusion and sanction regulations. Exclusion and sanction laws have long been a cornerstone of healthcare compliance, protecting patients and the government from fraud, waste, and abuse. This article will discuss exclusions and sanctions, why they matter, and how to stay compliant in a changing telehealth landscape.
What are exclusions and sanctions?
Exclusions and sanctions are legal actions taken against healthcare providers who are found to have engaged in fraud, waste, or abuse. Exclusions prevent healthcare providers from participating in federally funded healthcare programs like Medicare and Medicaid. On the other hand, sanctions are civil or criminal penalties imposed on healthcare providers who violate laws related to healthcare fraud, waste, or abuse.
Exclusions and sanctions are severe consequences for healthcare providers, as they can lead to loss of revenue, damage to reputation, and even criminal prosecution.
Healthcare providers who have been excluded or sanctioned are barred from participating in federal healthcare programs for a period ranging from a few years to a lifetime.
Why do exclusions and sanctions matter in the age of telehealth?
Exclusions and sanctions are particularly relevant in the age of telehealth because the shift to virtual care has brought about new opportunities for fraud, waste, and abuse. For example, telehealth providers may engage in upcoding or unbundling, where they bill for services that are not medically necessary or provided. In addition, telehealth providers may engage in kickbacks or self-referrals, receiving financial incentives for referring patients to other providers or ordering unnecessary tests or procedures.
Given the potential for fraud, waste, and abuse in telehealth, healthcare providers must remain vigilant in ensuring compliance with exclusion and sanction regulations.
How to stay compliant with the exclusion and sanction regulations in telehealth
To remain compliant with exclusion and sanction regulations in telehealth, healthcare providers should:
1. Conduct thorough screenings
Healthcare providers should thoroughly screen all employees, contractors, and vendors to ensure they are not excluded or sanctioned. This includes conducting regular checks of exclusion and sanction lists, such as the List of Excluded Individuals and Entities (LEIE) maintained by the Department of Health and Human Services (HHS).
2. Develop and implement compliance policies and procedures
Healthcare providers should develop and implement compliance policies and procedures that address the unique risks associated with telehealth. This includes ensuring that all telehealth services are medically necessary and properly documented and that all billing and coding practices are accurate and transparent.
3. Provide regular training and education
Healthcare providers should provide regular training and education to all employees, contractors, and vendors on exclusion and sanction regulations and best practices for maintaining compliance in telehealth. This includes training on proper documentation, coding, billing practices, and identifying and reporting potential violations.
4. Implement effective monitoring and auditing systems
Healthcare providers should implement effective monitoring and auditing systems to identify and address potential exclusion and sanction regulations violations. This includes conducting regular internal audits and reviews of telehealth services and implementing effective reporting and investigation procedures for potential abuses.
5. Work with experienced legal counsel
Healthcare providers should work with experienced legal counsel knowledgeable in exclusion and sanction regulations and the unique risks associated with telehealth. Legal counsel can guide compliance policies and procedures, address potential violations, and respond to government investigations.
Exclusions and sanctions are severe consequences for healthcare providers who engage in fraud, waste, or abuse, and the shift to telehealth has brought about new opportunities for potential violations.