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Hospitals and other healthcare institutions should carefully follow the Office of Inspector General Compliance Program Guidance. Medicare, Medicaid and other federal funding can be at risk otherwise. Serious fines, monetary assessments and the rigid regulation of Corporate Integrity Agreements can result from disregard of these standards. Screening employees, physicians and vendors is an important part of a proper compliance program, and it's critical that this compliance screening be done properly. What
you should know about personnel compliance screening
What
you should know about vendor compliance screening
Does OIG really expect us to do screening? In a word, yes. The Department of Health and Human Services (HHS) has charged its Office of Inspector General to find and eliminate overcharges and fraud in federal healthcare programs. Visit their website to learn more. A key element of this approach is "voluntary" self enforcement of OIG's Compliance Program Guidance for various segments of healthcare providers. The guidances issued for hospitals, hospices, long term care and physician groups all stress the exclusion of parties found to have been involved in defrauding government, patient abuse or drug trafficking. It is the responsibility of any entity seeking federal funds to comply with the guidance elements, including screening, or risk several unpleasant consequences if irregularities are found. Using powers given HHS by HIPAA, the Budget Act of 1997 and the False Claims Act, the OIG has real teeth to enforce compliance. In FY 2005 alone, OIG saved $35 billion, excluded 3,806 people and companies from Medicare/Medicaid reimbursement and prosecuted 537 criminal convictions and 262 civil actions. As part of compliance enforcement, over 400 healthcare entities have entered into stringent Corporate Integrity Agreements (CIA) after OIG became aware of overcharges and other irregularities. What if we don't do any screening? First, a little perspective. It is very unlikely that OIG will ever knock on your door just to see if you are doing this screening. Their resources instead are focused on finding overcharges and other fiscal irregularities. However, if they ever question your facility for those reasons, one of the things they will want is evidence that you have implemented a screening program. Here OIG's emphasis is on fraud prevention. The government provides you with lists showing people and businesses excluded from federal programs (like Medicare, Medicaid, TRICARE and others), and in turn they expect you to use the lists to prevent these parties from any association with your facility. See the OIG Compliance program for hospitals, page 8996 as one example. For another, see the online publication of the OIG Exclusion Authorities. If you have an encounter with OIG and you don't have a reasonable screening program to weed out those already convicted of government fraud, OIG indicates you probably can expect harsher treatment for your screening shortcomings. And OIG has real teeth to employ if it bites your facility: its Civil Monetary Penalty provisions provide a fine of up to $10,000 for each wrongful submission, plus an additional assessment of up to triple the amount wrongfully claimed, and possibly an onerous Corporate Integrity Agreement. In flagrant cases of financial abuse, it is even possible for all federal funds to be withheld from the provider facility. Who in our hospital needs to be screened? Very simply, everyone. The OIG Compliance program for hospitals on page 8994 plainly states your need to ensure that the lists "...have been checked with respect to all employees, medical staff and contractors." The definition of medical staff also includes physicians whose only connection with the hospital are staff privileges "since the hospital must be held accountable if the items or services are provided by excluded physicians." See OIG Exclusion Authorities, page 39424. Screen all personnel, or just caregivers? Everyone connected with the hospital, whether doctor, nurse or food service worker, is required to be screened. Through the Medicare Cost Report and similar mechanisms, the federal government in effect pays part of the overhead costs of the facility, including personnel costs. So, their position is that no excluded persons can be part of the costs paid by federal funds, even though they are not direct caregivers. There are no exceptions. Everyone gets screened against the federal government's two lists of excluded persons. Where do we get information for screening? To implement this screening, you are told by OIG to use two lists. The first is OIG's List of Excluded Individuals/Entities. Click on Exclusions Database, then click on Online Searchable Database to do your search. Over 33,000 individuals and over 2,000 organizations appear on this list. All of these exclusions are for healthcare related offenses. The other list is maintained by the General Service Administration (GSA) and is called the Excluded Party List System, Parties Excluded from Federal Programs by Name. Use the Search By Name option. A total of 53 federal agencies post data to the GSA list. While it also has most of the healthcare exclusions, its main use is to screen for non-healthcare fraud. Over 9,000 persons and over 3,500 businesses are excluded for non-healthcare reasons. Why is the GSA list checked also? The GSA list is required because even non-healthcare fraud can disqualify a person from working in a hospital. The Federal Acquisition Streamlining Act of 1994 states that parties barred or suspended from any federal program cannot participate in any other federally funded program such as Medicare or Medicaid. OIG claims a permissive authority in its OIG Exclusion Authorities, page 46687, to exclude based on a prior conviction for "...Fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct with respect to any act or omission in a program, other than a health care program, operated in whole or in part by any Federal, State, or local government agency." This means that a given listing on the GSA system can be sufficient for OIG to exclude a person for non-healthcare fraud convictions. OIG states in the OIG Supplemental Guidance Program its desire that parties be checked routinely “... against government sanctions lists, including the OIG’s List of Excluded Individuals/Entities (LEIE) and the General Services Administration's Excluded Parties Listing System.” Regarding
those healthcare entities operating under a CIA, OIG states on its
website: How often do we have to do this? You need to recheck all employees periodically. The OIG Supplemental Guidance Program, OIG states “...employees, contractors and medical staff [should be] checked routinely (e.g., at least annually)." OIG has commented to us that "As someone who has been employed could later be excluded, without periodic checking, the employer could be subjecting themselves to, at the very least, having to repay the programs for the services of the excluded individual/entity for which they billed the programs. In addition, they could possibly be subjecting themselves to civil monetary penalties.... Information about the entity's efforts to check would be considered in any determination about whether to impose a CMP." Should we screen personnel ourselves, or use professional help? The answer is, it's up to you. You can access the two federal databases on the internet yourself to screen new hires. Then, once a year you can attempt to rescreen all personnel yourselves. However, here are two main reasons to consider our professional assistance. First, screening can take a great deal of time, especially when you do the annual recheck of hundreds or thousands of names. Secondly, expertise is required to decide what to do when there are tentative name matches. Are you confident in your ability to make these decisions with so much potential risk to your facility? As professionals in the area of compliance screening, we focus exclusively on performing screening for our clients. We have developed special techniques which allow us to perform your screening in a timely and knowledgeable manner. Does FCRA prevent us from using Sterling? We have always believed that FCRA was not a factor when using our services for periodic rescreening of employees. Legal analysis indicates that the 2003 amendments to FCRA definitely exempt compliance screening because this rescreening is required under federal law and regulations. See FCRA Changes for details. How do you do personnel screening for your clients? Click here to find out. Will you tell us when a person or vendor is excluded? Yes, it is part of our services. We put it in writing for you. It is our intent to provide you with a complete assessment of the exclusion status of each party we review. If we believe a person or vendor to be an excluded party, we will report our findings to you, along with the details which lead us to that conclusion. Our track record is that we assess over 99.99% of the parties we review conclusively as either "Not Excluded" or "Excluded" from participation in federal healthcare programs. We try to leave no room for doubt. Why is it better to have Sterling do this screening? Click here to learn why. Will you do our new hire screening for us? We no longer offer new hire screening. However, there are several key points that we can share with you at no charge. We encourage you to perform new hire screening in house using these techniques. Why should we screen our vendors? While we believe that OIG probably has a higher priority for personnel screening, they also are sensitive to the firms your facility buys goods and services from. So, the short answer is yes, you should be screening vendors as well. Look at page 46678 of OIG Exclusion Authorities and you will find OIG's position that you cannot request reimbursement for any goods or services provided you by an excluded business "entity". Remember that the federal government in effect pays part of your "indirect" costs through the Medicare Cost Report and similar mechanisms. The Balanced Budget Act of 1997 makes you liable for a CMP if you contract "...with an individual or entity that [you] know or should know is excluded from participation in a federal health care program." The CMP amounts, triple restitution and other measures discussed above for employees and physicians also apply for excluded business entities. The OIG and GSA lists taken together have the names of over 40,000 persons and businesses excluded from federal programs. You are wise to make sure none are providing goods or services to your facility. How often should we check vendors? Consider these
comments from
the OIG website. "No program payment will be made for any
items
or
services furnished, ordered, or prescribed by an excluded individual or
entity..." and OIG has commented to us that ".... information about the entity's efforts to check would be considered in any determination about whether to impose a CMP." [Civil Monetary Penalty] So the longer you wait to check, a vendor which becomes excluded causes you ever increasing problems when finally discovered. Regarding personnel, OIG is clear in suggesting rechecks "at least annually". Many hospital attorneys and others in the compliance field recommend checking vendors every year as well. How do you do vendor screening for your clients? Click here to learn how. Can you send us written quotes, references and examples of screening reports? We will be pleased to send you pricing information, names and phone numbers of healthcare references and examples of our work. We recommend sending you this information as an e-mail with attachments, but we can fax or mail you hard copies if you prefer. We promise not to subject you to sales pressure or obnoxious follow up calls. Back
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