Keeping Your Healthcare Business Safe: A Simple Guide to Sanction Checks and Exclusion Screening

As a healthcare provider or other administrative workforce member, you are responsible for managing both the care your patients receive, as well as the many other required by law to operate in compliance. In addition to caring for patients, you must also manage the healthcare rules that govern how organizations must comply with state regulations in every aspect of running a business.

One of the most important duties on your organization’s to-do list includes regular background checks for employees, but the background checks we are discussing are different than the typical criminal background checks, as they relate to the type of checks your organization uses to ensure compliance and to prevent the organization from incurring large fines due to non-compliance.

In the following pages, we will clarify and explain three terms that seem to be confusing to many in the industry; these terms are Exclusion Screening, Sanction Check, and CMS Open Payments. For each term, we will provide an easy-to-understand explanation of what the term means in simple English.

What is the process of exclusion screening?

Think of it as a National Do Not Hire List in healthcare. In fact, there is one, and it’s called the Office of Inspector General (OIG).

When someone such as a doctor or nurse commits fraud or abuse against patients, defaults on student loans, or participates in other dishonest activities, they will be excluded from all future participation in the Federal Health Care Programs such as Medicare and Medicaid (these exclusions are called Exclusions).

By performing exclusion screening, you are screening your employees and vendors against the lists maintained by the OIG to ensure none of them have ever been excluded. If there is a false claim for services rendered by an employee who has been excluded from Federal Health Care Programs, it puts your practice at great risk for penalties that could potentially put your business out of business.

It’s also important to remember that exclusion screening is a recurring process; it’s not something that you should just do when you hire someone. Each month, new individuals throughout healthcare are added to the exclusion list, so it’s critical that you perform exclusion screenings on all staff members every month.

Sanction checks are distinct from exclusion checks because sanctions serve as a notification or punishment rather than an outright prohibition from participation.

Sanctions are typically found on state licensure (practice) board(s) and may include disciplinary action against a nurse for inappropriate conduct, or a physician for inappropriate prescribing.

Thus, a physician or provider may still possess an active license and may not have been excluded from participation in Medicare; however, they may have one or more active sanctions present against them. A thorough background check will provide insight into an individual’s quality of care history and protect patients from providers with a history of inappropriate actions; and, additionally, will protect an organization’s reputation.

What is open payments with CMS? 

Open payments are different from the other two types of exclusion and sanction because open payments focus on transparency. 

The pharmaceutical and medical device manufacturers previously had many reasons to believe that they could "buy" doctors' loyalty with journeys, extravagant gifts, and speaking fees. If there were any suspicions that your doctor prescribed a specific medication because they were compensated, that would raise a flag in terms of your safety. 

CMS has created open payment programs (also known as the Sunshine Act) as a means of addressing these concerns by requiring drug and device companies to document payments made to physicians and teaching hospitals through public access to this data. 

By reviewing CMS Open Payments  data, you will be able to determine whether or not your doctor is accepting payments from industry vendors, which will allow you to address any potential conflicts of interest before they escalate into a legal or public relations crisis.

In the End

Compliance is not meant to be intimidating or fear-inducing - you should have an effective compliance program that is always effective at meeting the standards of care provided to patients by their medical provider(s). Regularly completing exclusions screening for employees to verify eligibility to work as well as completing sanctions checks to verify employee professional history creates a buffer surrounding your business. Monitoring CMS Open Payment reports is another step to ensure financial transparency and that your patients will be provided with the highest level of quality care.

Completing these checks not only protects your business from any potential fines imposed by the government, but more importantly, it protects your patients by ensuring that the individuals who are providing care for them are trustworthy, qualified, and honest.