2011 HEAT Provider Compliance Training – Understanding Program Exclusions

By Adem Lewis / in , , , , , , , , /

>>Geeta Kaveti: Okay good morning. As Tony mentioned I am here today to talk to
you about understanding program exlusions. Again my name is Geeta Kaveti and I’m
also an attorney with the Administrative and Civil Remedies Branch
of the Office of Counsel. So let’s get started at the very beginning. What is exclusion? As Meredith and Tony mentioned this morning,
the OIG has the authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal healthcare
programs but what does this mean? What is a practical affect
of actually being excluded. While the practical affect of exclusion is that
no program payment may be made for any items or services, furnished ordered or prescribed
by any excluded individual or entity but let’s think about this in practice. For example, if a home healthcare aide provides
services to a Medicare or Medicaid beneficiary and that aide has been excluded, they would
not get paid for those services provided to program healthcare program beneficiaries. It is important to note that exclusion
does not prevent individuals or entities from working in the private sector. Exclusion applies only to federal
healthcare program payments. So another thing to think about in terms of
exclusion is that items for services furnished at the medical direction or prescription of
an excluded physician are not reimbursable when the individual or entity
furnishing the items or services knows or should have known about the exclusion. This applies even if the payments are going
to someone other than the excluded physician. So practically speaking if an excluded physician
orders a series of tests at your hospital, those tests may not be payable
unless you can show that you didn’t have any reason
to know about the exclusion. And that applies even if those are legitimately
provided services that were medically necessary for that feeral healthcare program beneficiary. It is also important to note that no federal
healthcare program payment can be made to cover an excluded individual’s
salary or benefits regardless of whether they provide direct patient care. In the example that Meredith cited this
morning about the skilled nursing facility that skilled nursing facility had
employed a nurse who was excluded and that skilled nursing facility had to
pay back a portion of that nurse’s salary and benefits associated with
federal healthcare program payments. So in the end the practical affect of
exclusion is to significantly reduce the ability of an excluded individual or entity
to find employment or contract with any healthcare provider who
receives direct or indirect payment from the federal healthcare programs. Okay so let’s think now that
we know some practical things about being excluded let’s learn
some basic facts about exclusion. As was mentioned earlier today there are two
types of exclusion mandatory and permissive. Under the OIG’s mandatory exclusion authorities
we are required to exclude individuals and entities who are convicted of certain
offenses such as convictions related to federal healthcare program crimes, patient
abuse or neglect, felony healthcare fraud and felony convictions related
to control substances. The OIG also has a number of
authorities which are permissive under which we may exclude individuals
and entities such as if an individual lies on an enrollment application or is
convicted of certain misdemeanor crimes, or loses a state license to practice,
fails to provide quality of care or fails to repay certain federal
healthcare program student loans. It is important to know that anyone can
be excluded not just licensed individuals so doctors, nurses, billers, secretaries, even
corporate entities and officers can be excluded. The length of exclusion is generally a defined
period of time but it may be indefinite for certain types of exclusions such as those
associated with the loss of a state license to practice or with a failure to repay
certain federal healthcare education loans. It is also important to understand
that the minimum period of exclusion for mandatory exclusions is five years;
but that exclusion period can be increased if there are aggravating factors present. The final note about exclusions is
that it is important to understand that reinstatement once your period of
exclusion has ended is not automatic. You have to apply to the
OIG and receive a notice that your reinstatement has been
granted before you can begin working with federal healthcare program beneficiaries. Let’s learn about checking about exclusion. We’ve heard a lot about the penalties
for employing and contracting with excluded individuals but how and
why should be screening every day– not every day on a regular basis. As Meredith mentioned there are CMP’s that apply if you employ a contract
with excluded individuals. CMP’s again are civil monetary penalties. CMP’s of up to $10,000 for each item or
service furnished and listed on a claim for federal healthcare program
reimbursement as well as an assessment of up to three times the amount
claimed, maybe imposed. Initially, the exclusion of the employer
can happen in certain extreme circumstances. Secondly, under the Affordable Care
Act the secretary of the Department of Health & Human Services also has
the authority to deny a provider number to anyone associated with an excluded party. So clearly there are some
strong incentives for you to be screening both your employees
and any contracted vendors. So let’s go to our website and
find out how you screen people. Okay so as was shown to you earlier this
is the homepage of our current website; and under the quick links box you can see
that there are links to the exclusions program and our online exclusions
database known as the list of excluded individuals entities or the LEIE. So let’s go to the exclusions
program page first. So on the exclusions program page you can find
a lot of the information that I’ve been talking about today as well as more in depth information on the exclusion authorities
and basic facts about exclusion. If you have further detailed
questions I would encourage you to explore this page particularly the frequently
asked questions section which provides a lot of answers to questions we
get on a regular basis. This page also has links to
the LEIE so let’s go there now. The LEIE is available and
searchable on line and as was shown on the previous screen it is also
available in a downloadable format. People much smarter than me and
much more technically savvy can take that downloadable file and match employee lists. I, of course, cannot tell you at all how to
do that but I’m sure there are capable people in your organizations who can figure it out. There is also information on the web about
how to use those downloadable databases. So this is our online searchable database and
I wanted to show you what happens on the screen when you put a name in and then my
fellow presenters always hate this moment because nobody never knows who
I’m going to pick to put in. But I figured today I would just go
straight to the top and we’ll check to make sure the inspector
general isn’t excluded. Okay you are not excluded so
we are happy to report that. This is the screen that you see
when you get negative results. It’s a screen that when you’re
screening for exclusion of your employees you should be saving it
as a part of your documentation process or find some other way to document
that you are doing your screens. Let’s look at what happens
when you get a positive result. Okay so you can see that when you get a
positive result you’ll get a list with the name, the general information about the
individual or entity that’s been excluded, certain specialty information,
the exclusion authority’s state such as common names as the one that I use. There are also opportunities to verify and you
can currently verify the social security number or employment identification number so there are
ways to verify beyond just looking at the name. So now that we’ve taken a look
around the website let’s go back and get some final screening tips so that I
can get you to the break in your first session. I wanted to leave you just a few
takeaways for you to take home when you go to screen in your own organizations. First, screen your employees and
vendors before hiring and contracting and on a regular basis thereafter. It is important to do that to avoid all the
liability associated with the employment and contracting with an excluded individual. Second, as you can see on the database
it’s very common to get multiple results. This is screen name, all variations of
names of an organization or an individual that you’re working with
including DBAs and former names. Make sure you have enough
identifying information to be able to ascertain whether your employees and contractors are the ones
actually shown on the screen. Finally, maintain proper
documentation of your searches. It is important to do so so that
you can prove it if an issue arises that you were doing the searches and
maintaining your own records appropriately. But what do you do if you have a match? What do you do if someone
that you’re working with shows up on the LEIE when you do your screens? You can consider a number of options:
One, consider removing the employee from their position while
you investigate the matter or work with them to discover what is going on. You could also consider the
appropriateness of certain bill holds for your employees or contractors. And finally as Tony and Meredith have mentioned,
employment of excluded individuals is one of the most common subjects of our
self-disclosures that we receive in our office, and Tony will be talking more
with you in the next session about how you can actually self-disclose
if you discover such an issue. With that, I would encourage you again just to explore our website and
get your questions answered. We will be on a break until 10:25. For those of you in the room the speakers will
make themselves available to answer questions. Otherwise we will be back at 10:25. Thank you.

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