In 1977, physicians and other practitioners were mandated to be excluded from participation in Medicare and Medicaid by the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Public Law 95-142 if convicted of program-related crimes. In 1981, the Civil Monetary Penalties Law (CMPL), Public 97-35, authorized the Office of Inspector General (OIG) to impose Civil Monetary Penalties (CMPs) and exclusions against persons having submitted false of fraudulent claims to Medicare and Medicaid. In 1996-1997 the OIG’s authority also expanded to all Federal Healthcare Programs (Medicare, Medicaid, Tricare, and Veterans Administration [VA]). This is important as the OIG may impose CMPs of up to $10,000 for each service furnished by an excluded person.

Who Has to Comply – The Short List?

  • Healthcare Providers/Health Systems
  • Home Health and Hospice Providers
  • Nursing Facilities and Assisted Living Facilities
  • Residential Support Services/Group Homes
  • Adult Day Care Centers
  • PACE Programs
  • Therapy Providers
  • Behavioral Health Providers
  • Some Healthcare Consulting and Billing Firms based upon the services offered
  • Most Health Information Technology Services Firms
  • Staffing Agencies

How Do I Determine Which Individuals to Screen?

The OIG recommends a detailed review of individual job categories and roles to determine if direct vs. indirect, in whole or in part, relationships or services provided are payable by a Federal health care program. If yes is the answer, then monthly exclusions are the best method to mitigate CMP liability. Employees, subcontractors, volunteers, board members, employee of contractors, and vendors who support directly or indirectly payment from Federal health care programs pose liability to practices. It is also recommended to review payer contracts, as many now contain language specifically requiring providers to conduct monthly exclusion checks as a Condition of Participation and Payment AND if this is not specifically listed, many payer contracts contain language requiring the provider to comply with Federal and State regulations.

What Types of Actions Can Result in Exclusion or Sanctions?

  • Fraudulent billing practice convictions
  • Defaulting on Federal loans, including student loans
  • Providing and billing for services based upon the referral or order of an excluded physician
  • Contracting with a vendor who is an excluded individual or vendor
  • State Medicaid Exclusion lists contain separate lists based upon state-specific payer exclusions and/or state Licensure Suspensions, which can be initiated by communication from Federal or State agencies
  • Certain criminal, civil, and misdemeanor offenses, which do not have to be healthcare related

How Can LW Consulting, Inc. Help?

LW Consulting, Inc. (LWCI) offers a cost-effective exclusions software, LWEnSCheck® Exclusions Software that entities can utilize in completing their monthly exclusions. LWCI exclusion consultants can set your team up to conduct monthly exclusions in our proprietary software and train your team on downloading the monthly reports for compliance retention. If your team has been struggling to keep up with monthly exclusions, outsource your work to our exclusion consultants. Our consultants conduct monthly exclusion services for health systems, health plans, and small providers.

Not sure where to start? Contact Ashley Popovich at [email protected] or call (570) 431-0100. We would be happy to talk through your exclusions process and how LWEnSCheck® can help!