Keep Your Patients Safe from Banned Healthcare Workers

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  • In Compliance
  • May 23, 2013
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Banned Healthcare WorkerThe U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) wants to be sure you don’t employ excluded individuals to care for government-insurance patients. They are cracking down on health care crooks and abusers and have listed individuals to steer clear of. OIG also provides information on excluded individuals and how to protect yourself from employing them.

Excluded Individuals Can Affect Payment and Liability

How does hiring an excluded individual affect your claims payments? According to the OIG’s “Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs”:

“The effect of an OIG exclusion is that no Federal health care program payment may be made for any items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person.”

This applies to all federal health care program payment methods, such as:

  • Itemized claims
  • Cost reports
  • Fee schedules
  • Capitated payments
  • Prospective payment systems or other bundled payment
  • Other payment systems

The prohibition of payment even applies “if the payment is made to a State agency or a person that is not excluded.”
In the bulletin, which supersedes the original from 1999, OIG uses an example of how an excluded individual would affect payment and be a liability if hired:

“… no payment may be made to a hospital for the items or services furnished by an excluded nurse to Federal health care program beneficiaries, even if the nurse’s services are not separately billed and are paid for as part of a Medicare diagnosis-related group payment received by the hospital. Also, the excluded nurse would be in violation of her exclusion for causing a claim to be submitted by the hospital for items or services the nurse furnished while excluded.”

Know Who Is on the Exclusion List

The latest exclusion list, “List of Excluded Individuals and Entities (LEIE),” was released on May 14 and includes 51,729 individuals banned from treating Medicare and Medicaid patients. The excluded individuals’ crimes include anything from not paying medical student loans to submitting fraudulent claims, and from patient abuse to murder. Non-payment of student loans is the most common reason for being banned.
Exclusions usually last from five years to life. When an exclusion expires, the individual must reapply to the OIG to be accepted back into federal healthcare programs.

Protect Your Practice

Penalties for an excluded person submitting a claim for payment to a federal healthcare program can be up to $10,000 “for each claimed item or service furnished during the period that the person was excluded,” says the OIG. Violations may also lead to criminal prosecutions or civil actions. There are other penalties that may apply, as well, in addition to civil monetary penalties for violating the exclusion.
According to the bulletin, providers are “subject to overpayment liability for any items or services furnished by any excluded person.” OIG says healthcare employers who care for Medicare and Medicaid patients need to perform monthly checks of their entire payroll rosters to ensure they aren’t employing excluded criminals. Healthcare employers can use LEIE database for exclusion screening.

Certified Professional Medical Auditor

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