Protecting against hiring or doing business with ‘excluded’ providers is a must for any healthcare organization.
Exclusion screening is a compliance process where healthcare organizations regularly check federal and state databases to ensure their employed or contracted providers, vendors, and entities are not excluded from participation in federally funded healthcare programs, such as Medicare and Medicaid.
An excluded provider is one who has been barred from participating in these programs due to certain infractions, such as fraud, abuse, criminal convictions related to healthcare, or noncompliance with program regulations.
Here we will discuss exclusion screening and why healthcare organizations need to screen providers.
Why is exclusion screening important?
Exclusion screening is a critical safeguard for patient care, organizational compliance, and financial sustainability. It is also a vital component of the provider credentialing process, ensuring that providers are legally and ethically eligible to deliver care. Failing to implement robust screening processes for providers and vendors puts organizations at significant legal, financial, and reputational risk.
A robust screening process helps to ensure a provider’s eligibility to treat patients and receive payments from federally funded healthcare programs. Vendor compliance backed by a sound vendor policy is equally important.
What are the consequences of noncompliance?
If an excluded individual or entity provides care, the healthcare organization may face legal and financial repercussions, operational disruptions, and damage to reputation and trust.
For example, the Office of Inspector General (OIG) can impose hefty fines and legal action. Noncompliance can result in exclusion from Medicare and Medicaid programs, which is a critical revenue stream for most hospitals.
Time-consuming audits and investigations can disrupt daily operations, and patients may lose confidence in the organization’s ability to ensure safe and ethical care.
What contributes to exclusion from federal healthcare programs?
There are several reasons an individual or entity may be excluded from participating in federally funded healthcare programs. Examples include fraud, patient abuse or neglect, criminal convictions, and substance abuse, among others.
Additionally, an exclusion can be triggered by an adverse action by a state licensing board or failure to repay a Health Education Assistance Loan. Individuals controlling a sanctioned entity and entities controlled by a sanctioned individual can also be excluded.
How does exclusion screening work?
Exclusion screening involves regularly checking healthcare providers, employees, contractors, and vendors against state exclusion databases to ensure they are not barred from participating in federally funded programs.
Exclusion screening allows your organization to:
- Perform exclusion screening checks on individuals or entities with quick results
- Compare providers in your database with those listed in the OIG, System for Award Management (SAM), and state Medicaid databases
- Identify providers who are excluded from providing services and billing to Medicare and Medicaid patients
- Dismiss or confirm potential matches for individuals or institutions within minutes
How frequently should organizations screen?
The OIG recommends screening employees and contractors at the time of hire and monthly thereafter to capture any new exclusions.
Who should be screened?
The latest guidance states that those who have direct and indirect patient contact should be screened, including anyone supplying goods or services.
Beyond screening practitioners, healthcare organizations must consider whether to screen for hospital volunteers and professionals in training (for example, nursing students). It is highly recommended that screening be performed even if the provider is not receiving federal healthcare dollars.
What exclusion lists should be checked?
The best protection against working with excluded individuals or entities includes searching a host of federal and state exclusion lists. The OIG’s List of Excluded Individuals and Entities (LEIE) is the main exclusion list. However, healthcare employers are wise to monitor the SAM database and the 34 state Medicaid exclusion lists.
Who needs to perform exclusion screening?
Exclusion screening is required for any organization providing healthcare services that are reimbursed by federally funded programs like Medicare, Medicaid, or other government healthcare initiatives.
Organizations may include hospitals, private practices, clinics, long-term care facilities, third-party vendors supplying medical equipment or services, pharmacies, and laboratories.
Improve your exclusion screening
Exclusion screening is a critical compliance measure for all healthcare organizations, protecting patient safety and ensuring the integrity of federally funded healthcare programs. By utilizing exclusion screening software, organizations can streamline the process of identifying and managing excluded individuals and entities to stay compliant with federal and state regulations.
