Executive Brief Series: Insights on Recent OIG Enforcement Actions & Trends

A Closer Look at Summa Health: A Trifecta of Exclusions

Written by A. Michael Rosen, Esq. and Donna Thiel

summa health exclusions

In January 2022, an OIG enforcement action on Summa Health, Ohio resulted in a $19,880.28 penalty for allegedly violating the Civil Monetary Penalties Law after Summa Health self-disclosed. The OIG alleged that Summa employed an individual on the Ohio Provider Medicaid Exclusion and Suspension List as well as an individual who was excluded from participation in Federal health care programs. The OIG also alleged that “Summa billed the Medicaid program or paid for claims through its Medicare Advantage Plan, SummaCare, for services or durable medical equipment ordered by three physicians who were excluded and who were not on the Summa Health medical staff.”

In this particular case, the exclusion came from the Ohio Provider Medicaid Exclusion and Suspension List. If you are not monitoring state exclusion and suspension lists, you are opening your organization up to risk. On average over the last several years, it takes 173 days for a state Medicaid exclusion to appear on the OIG List of Excluded Individuals and Entities (LEIE). If you are only monitoring Federal exclusion lists, you could be 6 months delayed in identifying an excluded individual or entity that first appeared as a state Medicaid exclusion. These enforcement actions and repayments could have been avoided with state-level monitoring of all employees, vendors, and employees of vendors in addition to Federal exclusion list monitoring.

Additionally, this case involves both a payer and provider – a rarity. This situation involved an employee and an ordering provider which underscores the necessity of one platform to monitor every unique population. Remember that a healthcare organization cannot accept a referral or an order for a prescription from an excluded provider. When you manage risk from one centralized place, you can ensure that you don’t miss an exclusion across any of your populations, no matter how nuanced each population’s monitoring may be. In addition, with a fully automated monitoring solution that provides exact match results, you can ensure you never miss a lag between the state and Federal exclusion lists with timely identification of exclusions. It’s crucial to be able to analyze and interpret primary sources across every state and healthcare discipline to maintain compliance for your organization.

NOTE: As of May 1, 2022, the OIG has issued 1.8 million dollars in penalties related to exclusion, ranging from $10,000 to $281,000 for an individual who was excluded. This wide range demonstrates that already in the first 4 months of this year, the OIG is extremely active in enforcing exclusion-related compliance issues. In addition to employed populations, it is clear that the OIG is focusing on non-employed providers, referring and ordering providers, and exclusions at the state level.

Reimagine Your Exclusion List Monitoring with ProviderTrust

Michael Rosen, Esq.

A. Michael Rosen, Esq.

Partner, Co-founder, ProviderTrust

Michael is an expert in designing and developing innovative tools in risk management and compliance industries that tackle real-world problems that make healthcare smarter and safer. He brings over 25 years of experience in founding and leading service-oriented businesses and is an active speaker and presenter at compliance, legal, and risk conferences.

Donna Thiel
Donna Thiel

Chief Compliance Officer, ProviderTrust

Donna brings over 30 years of experience in the long-term care industry to lead the vision, execution, and strategy of our compliance vertical and operation. She is an active speaker on compliance strategy and an industry thought leader.

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