What Providers Need to Know to about OIG Checks

What Providers Need to Know to about OIG Checks

United States based healthcare providers should be vigilant in running their businesses. The Office of the Inspector General (OIG) places individuals or entities committing fraud or abuse under an exclusion list. This is called the List of Excluded Individuals & Entities (LEIE). Those appearing on this OIG list may not render any service or give items connected to federal healthcare programs. You may be found liable by the OIG if such were performed while under employment or contract with your business. Conducting an OIG search will help you be compliant and avoid any Civil Monetary Penalties (CMP). This makes it incumbent upon you to screen not only your employees but also third party vendors.

OIG LEIE company-wide application

Remember, your OIG exclusion check must not be limited to healthcare professionals primarily concerned with patient care. This should also include employees providing support services. The LEIE check should cover the administrative staff and even managers. It does not matter if they do not have any interaction with the patients. What the OIG checks for is if such excluded individuals are connected with your business while participating in federal healthcare programs. You will be in violation of the law every time they carry out their functions in relation to your business.

Scope of OIG sanction list

Section 1128 of the Social Security Act (SSA) clearly provide for exclusion in two types. There is mandatory and permissive exclusion. Being included in either would place you or your business on the OIG list. Both prevent you from receiving reimbursement from federal healthcare programs.

Mandatory exclusions can involve the following:

  • Conviction of program-related crimes
  • Conviction relating to patient abuse or neglect
  • Felony conviction relating to health care fraud
  • Felony conviction relating to controlled substance 

These would merit 5 years in the LEIE database. Being convicted with a second mandatory offense will be 10 years. A third time or more however will result in permanent exclusion from Medicare, Medicaid and federal healthcare programs. 

Permissive exclusions contain a variety of acts. They are listed under Section 1128 of the SSA as well though you may also be liable under Section 1156 of the same Act. Briefly, these entail some of the following:

  • Misdemeanors relating to fraud or controlled substances
  • Convictions related to fraud in non-healthcare programs or obstruction of an investigation or audit
  • License revocation, suspension or surrender
  • Failure to meet statutory obligations of practitioners and providers

It is at the OIG’s discretion on how it will decide on such grounds for exclusion. This could merit anywhere between 1 to 3 years on the OIG federal exclusion list. In spite of this, there are other grounds which will result in different periods under permissive exclusion.

The finer points

The grounds listed under mandatory exclusions will force the OIG’s hand to place violators in the LEIE. Those caught performing acts prohibited under permissive exclusions however are at the discretion of the OIG. The effect for both mandatory and permissive exclusion is the same. All are excluded from participating in federal and statewide healthcare programs. There are no differentiating factors once you are on the list. Only the duration will vary but not the exclusion.

Note that those on the OIG list are only limited from joining in Medicare and Medicaid programs. They are free to provide services privately as long as there is no involvement with government backed healthcare programs. Patients however are at potentially at risk of receiving services from ethically questionable healthcare practitioners or providers.

Use different databases

The OIG LEIE is an excellent tool to utilize for OIG searches. It contains a vast amount of excluded names in the healthcare industry and is quite easy to use. You can do a manual OIG check by simply downloading the LEIE database. Another way to search for exclusions is through the web portal of the OIG. Despite the extensive number of individuals and entities listed here, it cannot be considered as complete. It is highly advisable to extend your search to the System for Awards Management (SAM) database.

The SAM provides a broader search because it compiles other federal databases into its central repository. This includes what used to be known as the Excluded Parties List System (EPLS).  It is a bit more cumbersome though it does the job nonetheless. You must not seek reimbursement for employees or vendors found on such lists. Note that while the LEIE, SAM and EPLS all involve exclusions, these databases are not the same. You may find more information about them here Differences Between the OIG’s LEIE and GSA’s SAM Exclusion Lists .

Regular OIG searches, or else

By now you probably already have a general idea on what OIG checks are. It is natural however if you are still having some difficulty grasping some of its concepts. This next section though may have a good probability of being clearly understood: 

Failing to perform routine OIG searches on your pre-hires, present employees and vendors can easily cost you fines within the $10,000 to $250,000 range. 

Yes, it has happened numerous times before. That is also a conservative margin. There have been multiple cases where it has gone well beyond the $250,000 mark. Violators have reached millions of dollars in fines on separate occasions, this year alone. The OIG makes no distinctions. Healthcare providers “who know or should have known” of excluded individuals or entities they transact with will equally be liable.

You can rely on the Compliance Resources provided by the OIG to help you with your next OIG exclusion search. It includes handy training programs to improve your capabilities in performing LEIE checks. Note however that this may hardly be enough to completely perform what is necessary.

There is an easy solution

Being able to do consistent OIG background checks is hard enough. Keeping track of all the updates on the LEIE database may prove to be too much. You might already be screening on a regular basis. This would however prove to be pointless if the names you are performing an OIG exclusions search on are in Monthly updates to the LEIE are released on a regular basis. You must update and synchronize your list to reflect the newer versions. This is something which healthcare providers should be constantly aware of. The OIG can still hold you accountable if you miss such updates despite your regular OIG exclusion checks.

Why leave it to chance when you can automate your processes with Streamline Verify’s proprietary exclusion software? It can provide you with preset OIG background checks for federal level databases such as the LEIE and the SAM. You will also be able to screen state level databases for individuals and entities specifically excluded in such jurisdictions. In addition, the software could extend its screening capabilities to look into various sanction lists and licensing lists.

Why wait until your business is slapped with thousands or even millions of dollars in avoidable fines? Benjamin Franklin’s “an ounce of prevention is worth a pound of cure” oft-cited phrase once again finds application here.