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

There are many concerns that any healthcare organization has to face; patient care, staffing and billing to name a few. However, there is one thing that will cost you a fortune if not taken care of, it could destroy your company's reputation as well; the process of checking all of your new hires or those who you conduct business with.

This type of check is referred to as sanctions checks or exclusion screening. Although this may sound heavy and legal in connotation, the concept itself is really quite simple and can be thought of the same way you think of a "No Fly List." 

This guide will provide everything you need to know regarding these types of screening processes including, what they are and why they are important, as well as how to successfully conduct them without added stress to yourself or your organization.

What is Exclusion Screening?

At the national level, the Office of Inspector General (OIG) keeps records on individuals and entities that can't participate in federal health programmes, such as Medicare, Medicaid, and TRICARE.

Persons appear on this list for a variety of reasons, including:

1. Committing Medicare fraud.

2. Neglect or abuse of patients.

3. Felony convictions for drugs or theft.

4. Defaulting on a Federal Student Loan.

Exclusion screening is the process of verifying that you have screened your employees and vendors against this exclusion list. If you hire someone that is on this exclusion list, the government will not pay for any health care service they performed on behalf of your company. Additionally, you are liable for a penalty of hundreds of thousands of dollars for each claim filed for services from an excluded individual or entity.

What are Sanction Verifications?

Sanction verifications differ from exclusions in that exclusions are national bans on billing to the Medicare or Medicaid programs, while sanctions are any disciplinary actions taken against a healthcare professional, including actions that may affect one's right to practice as a healthcare provider in a specific state.

A nurse may be placed under sanction in one state and therefore may not have any sanctions listed on the OIG exclusion list. Sanction verification involves conducting an exhaustive search for sanctions against all healthcare providers who treat your patients to ensure they are licensed and have no outstanding disciplinary actions against them with respect to their state licensing board.

The Reason Businesses Need To Conduct Exclusions Checks Every Month

When hiring an employee into your organization, it is not uncommon for an organization’s management team(s) to only run exclusion checks on potential hires at the time of their hiring and never run them again after that point. The OIG updates its exclusions list every month. Therefore, an employee who is winning will be placed on the OIG’s list of excluded individuals before they are hired or assigned to job duties on a record basis.

In order for an organization to maintain compliance with the law, they must conduct a monthly exclusions check. By only having a potential hire check completed at the time of their hiring, the organization will have unintentionally removed themselves from compliance allowing the possibility of that hire continuing to work for the organization if he/she becomes excluded.

The Risks of Ignoring This

If you fail to perform regular sanction checks and exclusion screening, the consequences are severe:

1. Massive Fines: The Civil Monetary Penalties can be upwards of $20,000 for each item or service claimed while an excluded individual was working for you.

2. Paybacks: You will have to pay back every cent you received from Medicare or Medicaid for the work that person did.

3. Reputation Damage: Your patients trust you to hire safe, qualified people. Employing someone with a history of fraud or abuse breaks that trust.

Making the Exclusions Screening Process Easy

It is virtually impossible to manually check every vendor and employee against multiple state and federal databases each month; the amount of time required to check and find multiple records can create a number of different opportunities for errors such as combining two people with the same name into one person.

The most effective way to conduct exclusion screening is to use an automated software tool. These tools perform automated monthly reviews of the OIG, SAM.gov and state Medicaid lists for you. They provide you with an alert if there is a potential match and allow you to spend your time providing patient care rather than reviewing spreadsheets.

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Summary

Compliance is an important factor in the healthcare industry. Knowing the distinction between sanction checks vs. exclusion screenings, and performing them on a monthly basis will help to protect the organization’s revenues as well as the health of the patients. Don't expect to be fined before you discover that your process for screening employees has deficiencies--start taking the steps necessary to protect your organization immediately!