Fall has arrived, and the anticipation builds for the holiday season. But first, stats! How was your 3rd quarter this year? Did you have any setbacks, team changes, new challenges you weren’t expecting? One thing we’d like to take off your plate is gathering exclusion data from Q3 for each individual state Medicaid list and all federal exclusion sources (OIG LEIE, SAM.gov).
Our data scientists + automated solutions remain diligent and accurate with matching records and data to give you a complete picture to help make the best decisions when it comes to exclusion monitoring, license verification, sanction screening, and more! Let’s take a look at the most recent trends from Q3 results in the latest edition of the Compliance Healthcare Index Report by ProviderTrust.
2018 Q3 Healthcare Exclusion Takeaways
In Q3 of 2018, the total number of healthcare-related exclusions at the state and federal level surpassed 200,000. This trend of increased state and federal exclusions is indicative of the coordinated efforts of a Medicare Fraud Strike Force and the active state Medicaid Fraud Control Units (MFCU) across the nation.
The shady business of fraud in healthcare continues to involve more elaborate schemes and organized criminals attempting to take advantage of the large sums of federal healthcare dollars. To combat these efforts the OIG, DOJ, DEA and the MFCU’s continue to use smart data and more investigators to take down bad actors. Law enforcement still maintains a positive return on their investment of $7 returned per each dollar spent, according to the OIG Semi-Annual Report.
Medicaid Fraud Control Units (MFCUs) Reporting
Unfortunately, there is a dilemma in timeliness of state reporting to the Office of Inspector General at HHS. Did you know that according to Performance Standard 8, OIG calls for all state Medicaid Fraud Control Units to transmit information to the OIG for HHS?
HHS OIG Requirement of Medicaid Fraud Control Units
for purposes of program exclusions under section 1128 of the Social Security Act, all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea agreements, and sentencing orders.”
Id. p. 32648.
The discrepancy between state Medicaid lists and federal exclusion data (OIG LEIE) can cause major problems for your organization when it comes to hiring and working with vendors or third parties. When you take the civil and monetary fines imposed in 2017 (including $5.2M for hiring or contracting excluded providers) into account, it’s urgent to understand the importance of ongoing exclusion monitoring as a part of your compliance program.
HHS OIG LEIE 2018 August Updates
Every month, HHS Office of Inspector General (OIG) updates its list of excluded individuals and entities usually around the middle of each month. This last August, three updates were announced causing some confusion around the most current sources for reference.
The first List of Excluded Individuals and Entities (LEIE) update was uploaded, as expected on 8/10; however, two out of cycle updates on 8/22 and 8/28 were also published. Since this was out of the ordinary and both files contained data different from the 8/10 file, ProviderTrust’s Data and Monitoring team reached out to the OIG for clarification. In both cases, we were instructed to continue searching against the 8/10/2018 version of the LEIE because the later month updates were inadvertently published.
2018 Q3 Healthcare Exclusion Data
OIG LEIE
Total: 70,379
SAM.gov
Total: 69,695
State Medicaid Exclusion Lists
Total: 65,695
Federal + State Exclusion Lists
Total: 205,769
2018 Q3 State Medicaid Exclusion Data
Top 5 States with the Most Exclusions
- California
- Texas
- New York
- Pennsylvania
- New Jersey
Once again, California remains at the top of the list for most state Medicaid exclusions according to the California Medi-Cal Exclusion List. OIG’s most recent audit of California MFCU showed the following information below.
New York and New Jersey Medicaid Fraud Control Units (MFCUs) 2017 Onsite Inspections
On September 25, OIG released a couple reports outlining the reviews of both the New York and New Jersey Medicaid Fraud Control Units (MFCUs). The inspections yielding acknowledgments that in general, each Unit operated in accordance with applicable laws, regulations, policy transmittals, and the MFCU performance standards. However, Unit improvements with timely reporting and documentation came into questions as far as effective investigations and process control are concerned.
Find out more about each state’s excluded individuals and entities by clicking on the map below!
Civil Monetary Penalties
Civil monetary penalties are the fines levied against healthcare organizations for doing business with an excluded individual or entity. The Office of Inspector General (OIG) allows organizations to self-disclose in exchange for a lesser fine. If the above cases had been enforced to their fullest extent by the OIG, the total fines could have exceeded $64,000,000.
Healthcare Exclusion Insights
We are proud to continue to provide insight into how your compliance program is stacking up against the rest, and help you understand the time dilemma between state exclusion reporting to OIG. According to our data, the average time it takes for states to report exclusion issues to OIG is 169 days. To dive deeper into our report and discover the most updated stats on the state of exclusions across the country – visit our CHIRP page!
Written by Michael Rosen, ESQ
Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.
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