Why Screening Matters: Navigating OIG Exclusions and Open Payments

Working in the healthcare industry involves much more than just treating patients. Behind the scenes, there is a massive web of rules and regulations designed to keep the system honest and safe. For healthcare organizations, HR managers, and compliance officers, staying on top of these rules is critical.

If you are managing a medical practice or a healthcare organization, you have likely heard terms like OIG Excluded, Exclusion screening, and CMS Open Payments. While these terms might sound like heavy legal jargon, they are actually quite simple concepts that protect your business and your patients.

When federal healthcare programs, like Medicare and Medicaid, try to eliminate the fraud and waste that is a part of their systems, they do so through the efforts of the Office of Inspector General (OIG). The OIG maintains a list of all of the individuals and entities that are OIG Excluded based on the crimes they were convicted of committing, such as, but not limited to, Medicare fraud or patient abuse, or felonies related to providing healthcare to patients.

For all intents and purposes, the OIG Excluded list is a federal "DO NOT HIRE" list. Once you are on the OIG Excluded list, you are prohibited from any participation in federal healthcare programs. Therefore, if you are a hospital or clinic that receives funding from Medicare, you cannot employ anyone that is OIG Excluded. If you hire an OIG Excluded individual as an independent contractor, or as a volunteer, you, as an employer, will be subject to substantial fines and penalties.

The Importance of Conducting Exclusion Screening of Staff, Vendors, and Contractors

How can you prevent hiring staff who are excluded from doing business with the government? The answer is to conduct exclusion screenings of your employees, contractors and vendors.

Exclusion screening means to verify through available sources whether your employees, vendors or contractors appear on the OIG exclusion list and, in many cases, state-level Medicaid exclusion lists as well, before employing them.

Many organizations perform this verification only once, when they hire a new employee. However, it is important to remember that an employee may have been excluded after they were hired, and therefore, it is recommended that an organization perform the exclusion screening of their employees, contractors and vendors at least once each month as a best practice.

By performing this type of screening on a regular basis, an organization will be able to "prove" to regulators that they have exercised appropriate due diligence to ensure there are no excluded employees working in their organization.

Understanding CMS Open Payments

While OIG exclusions deal with "bad actors," CMS Open Payments deals with transparency and money.

Run by the Centers for Medicare & Medicaid Services (CMS), the Open Payments program is a national database that promotes transparency. It tracks the financial relationships between healthcare providers (like doctors and teaching hospitals) and the drug or medical device companies that sell to them.

Why does this exist? In the past, there was concern that doctors might prescribe a certain drug just because the drug company gave them expensive gifts, paid for their travel, or gave them large consulting fees. This is a conflict of interest.

CMS Open Payments requires these companies to report payments made to providers. This data is then published online for the public to see.

For an organization involved in health care, comprehension of these three components has two primary implications:

First, financial security. Failing to properly conduct exclusion screenings may result in substantial monetary penalties for violations of civil law, as well as damages incurred as a result of improperly reported data related to open payments (if you manufacture products), and/or the inability to monitor your providers' data may lead to exposure to compliance audits.

Next, reputation. Patients are more knowledgeable than they were previously. Patients not only want assurance that they are receiving treatment within an environment devoid of OIG sanctioned personnel but also want assurances that the physician providing services has a transparent financial relationship with the hospital/organization.

Conclusion

Compliance doesn't have to be a headache. It is simply a way of ensuring that the healthcare system runs fairly. By staying vigilant with your Exclusion screening to catch anyone who is OIG Excluded, and by understanding the data within CMS Open Payments, you protect your organization’s reputation and bottom line.

A little bit of checking goes a long way in keeping your healthcare business healthy.