The most common reason healthcare companies switch to ProviderTrust is because their old process has become unsustainable. But often, our clients get a surprise during implementation: excluded providers who have been undetected in their populations for years. How does this happen? How does ProviderTrust find these sneaky exclusions?
In this post, we explore how our data enrichment strategy caught a long-undetected exclusion—a discovery that impressed the OIG enough for them to drop an investigation.
As we’re all too aware, low-cost OIG exclusion screening vendors can introduce significant risk into organizations by way of false negative results: excluded individuals in populations that their algorithms aren’t sophisticated enough to detect. Perhaps the excluded individual is using a different name or concealed information in some other way. This is what happened to a large home health client who got a wake-up call while onboarding with ProviderTrust.
As soon as we set up this client’s monitoring environment in Passport, we discovered an excluded provider among their employees. The name did not match, but the social security number did.
"How did you find that?" The Magic of Data Enrichment
Okay, it’s much more science than magic, but data enrichment still makes things appear that were previously invisible. Since most exclusion monitoring vendors only rely on publicly available data, such as name, address, and specialty to verify exclusions and match on data fields, they’re often unreliable. At ProviderTrust, we add uniquely identifying data, such as NPI, SSN, DOB, former names, and address history to public exclusion records. With thousands more data points, we are able to make connections that other vendors can’t, then we fully verify and confirm that match before passing it along to our client.
In the case of this client, the exclusion we matched was a Texas state exclusion that had been published in 2010. The excluded individual was hired by our client in 2015, and the match was discovered during the client’s onboarding with ProviderTrust in 2017.
An Undetected Exclusion
When the exclusion was discovered, we alerted the client of the findings, including the enriched data used to verify the match. After our alert, our client terminated the employee and started an investigation into how such an exclusion remained under the radar for as long as it did.
The client discovered that the excluded individual had changed her name between becoming excluded in 2010 and getting hired in 2015. The name she supplied in her employment application turned up no red flags during pre-hire screening.
An OIG Investigation Ensued
With a recommendation from outside legal counsel, our client disclosed the exclusion to the state of Texas. After our client terminated the excluded individual, she applied for reinstatement to the federal OIG, despite the fact that she was only excluded by the state of Texas. By applying for a reinstatement, a red flag was raised at OIG, and an investigation ensued.
However, with all the information we provided, plus the evidence that the provider issued an alternative name, the agency allowed payback of monies and wages without punitive damages. As the investigation closed, no further action was required.
How Many Exclusions are Hiding in Your Populations?
After experiencing an immediate ROI with our services, this client asked, “What else have we been unaware of?” and went on to add primary source license verification and other services to their ongoing monitoring program. They eliminated the challenge of directly interacting with dozens of state licensing boards, and created an authoritative data source in Passport, where licenses can be stored and updated in real-time.
Because a lot of excluded providers come up with sneaky ways to defraud federal healthcare programs, it’s typical for us to find undetected exclusions when we onboard new clients.
To avoid hidden OIG exclusions that bring risk into your organization, don’t rely on monitoring services that depend only on publicly available data. For a partner who invests time and energy into data enrichment to deliver a superior result, choose ProviderTrust.