A Closer Look at Summa Health: A Trifecta of 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.