Keep Your Healthcare Practice Safe: Understanding OIG Checks and Open Payments

As healthcare professionals, there are many operational aspects associated with keeping your facilities functioning including, but not limited to, insurance claims and patient medical records and there is also a great deal of back-end screening that is necessary for maintaining compliance and safeguarding your practice.

Today, we are going to discuss, in plain and simple language, some commonly used terms in compliance—namely the Office of Inspector General (OIG) and Centers for Medicare/Medicaid Services (CMS)—and how they can become a component of daily operations.

What is the Exclusions List of the OIG?

The OIG exists with the sole purpose of ensuring the integrity of programs run by the Department of Health and Human Services such as Medicare and Medicaid. The Exclusions List of Individuals/Entities (Exclusions List) is one of the primary methods used by the OIG to accomplish its mission.

Think of the Exclusions List OIG maintains as a National Do Not Hire List for Healthcare.

The Exclusions List is comprised of individuals or businesses that the OIG has determined should not be allowed to participate in the Medicare Medicaid programs due to their past behavior. For example, some individuals may have been convicted of fraud in relation to the Medicare program or have a history of abusing patients. Others may have been excluded based upon felony convictions concerning the distribution of controlled substances, or, in some cases, a failure to repay their student loans.

The Importance of the OIG Check

The most critical aspect of hiring healthcare professionals is that if an individual is on the Office of Inspector General OIG exclusion list, no Federal Healthcare Program can reimburse for any goods or services provided, ordered, or prescribed by that individual.

If you hire a nurse, billing clerk, physician, etc., who is on the exclusion list and they perform services for which you ultimately bill Medicare or Medicaid, you have exposed yourself to liability. You will likely have to reimburse the amount earned during the period of employment and could also incur substantial penalties (Civil Monetary Penalties).

This is why conducting an OIG Check monthly is so imperative.

The vast majority of practices believe that performing an OIG Check only on new employees is sufficient. The OIG publishes a new exclusion list every month, thus individuals who clear on January could be excluded in June. For your protection, you should conduct OIG Checks for all employees and vendors regularly; it is a simple step to take to prevent financial problems later.

What is Open Payments CMS? 

While the OIG is targeting "bad actors" and fraud, the CMS is focusing on testing. The Open Payments CMS program encourages physicians and other healthcare providers to engage in openness and transparency with their patients regarding their financial relationships with drug and medical device companies. 

The Open Payments program is a federal program that helps provide information about financial transactions between the medical industry (pharmaceutical companies, medical device manufacturers, etc.) and healthcare providers (physicians and teaching hospitals). It's easy to follow. If a pharmaceutical company pays a speaker to present at a conference, buys them an expensive meal, or provides them with transportation, the pharmaceutical company is required to report this payment to the Open Payments CMS. 

The Open Payments database does not constitute an indication of guilt on the part of a physician, nor does it mean a physician acted improperly. Consultations for pharmaceutical companies are completely legitimate for physicians. The intent of the Open Payments program is to inform the public of potential financial conflicts of interest so that they may better understand the motivations behind clinical decisions.

Summary

Compliance should not be viewed as a daunting task, but it absolutely must be done consistently.

To safeguard your practice, be sure to fully understand the distinction between these two lists and always make certain that all of your employees meet the criteria required to be eligible to work based on the appropriate list provided by the Government (OIG). Also, keep track of the Open Payments data being provided by the Centers for Medicare & Medicaid Services (CMS) so that you can have transparency regarding any financial relationships with the medical device and pharmaceutical industries.

By doing this regularly, you can ensure that your focus is on what really matters: Providing Excellent Care to all your Patients!