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OIG data analysis finds hidden excluded providers

Posted by Margaret Scavotto, JD, CHC on 12/22/14 7:00 AM

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A Texas company that operates 74 long term care facilities entered a $357,341.96 settlement with the OIG to resolve allegations that 7 of its institutions employed an excluded provider.

How did the OIG know this company employed excluded providers?

The OIG’s use of data analytics found 5 excluded providers. During the investigation, the long term care company found and self-disclosed two additional employees.

Could my company be inadvertently employing an excluded provider?

An excluded provider is an individual or a company that is prohibited from doing business with federal health care programs. These programs (e.g. Medicare, Medicaid) will not pay for services rendered by excluded providers. Individuals and contractors can becom

e excluded providers for a variety of reasons, including Medicare or Medicaid fraud; patient abuse or neglect; health care related felonies; controlled substance felonies; some misdemeanors; suspension or revocation of a health care license; provision of unnecessary services; submission of false claims; and participation in illegal kickbacks. Exclusions are typically for three to five years - but can be permanent. The only way to know if you are employing an excluded provider is to check the OIG's List of Excluded Individuals and Entities. If your state Medicaid program operates an exclusion list, it's important to check that list too.

What are the penalties for employing an excluded provider?

Your exposure in this area can be significant if an employee or contractor is added to an exclusion list without your knowledge. Any Federal health care program payments made to a provider for services rendered by an excluded provider are to be multiplied by three and returned. In addition, providers can be assessed a Civil Monetary Penalty of up to $10,000 per claim, and risk joining the list of excluded providers themselves. 

Big problem, easy solution

It is easy for the OIG to identify excluded providers using data analytics. Fortunately, it is also easy for providers to screen their employees. The OIG offers a Do-It-Yourself method. Plus, many software companies offer affordable solutions to automate this process.

Data analytics are a powerful compliance tool for enforcers and providers alike!

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