To be compliant with Centers for Medicare and Medicaid Services (CMS) payment eligibility and to mitigate your organization’s risk of HHS OIG fines and/or penalties, it’s important to include a comprehensive approach to monitoring your referring, ordering, and prescribing physicians. It is critical that these populations are being screened and evaluated before a claim is submitted to ensure that excluded providers are not participating in a manner that is prohibited to be reimbursed by the CMS. In this post, we’ll explore some of the relationships between providers and these external partners and how to help keep patients and your organization safe.

HHS OIG Special Advisory Bulletin: Effect of Exclusions in Federal Health Programs 

The HHS Office of Inspector General (OIG) submitted a Special Advisory Bulletin in 2013, outlining the scope, frequency, and effect of screening employees and contractors to determine whether they are excluded persons. The bulletin describes the situations in which referring providers are non-compliant with federal healthcare laws while “furnishing, ordering, or prescribing any services or items for the referred patient.”

Referring Providers and Exclusion from Federal Healthcare Programs 

According to the HHS OIG, an excluded provider may refer a patient to a non-excluded provider only if the excluded individual does not furnish, order, or prescribe any services for the referred patient, and the non-excluded provider treats the patient and independently bills federal healthcare programs for the items or services that he or she provides.

However, any items and services furnished at the medical direction or on the prescription of an excluded person are not payable when the person furnishing the items or services either knows or should know of the exclusion. 


How to Screen Referring, Ordering, and Prescribing Providers

  1. Define your healthcare referring populations (physicians, NPs, PAs, etc.)
  2. Identify referral networks by line of business, department involved, geography, and more. 
  3. Discover who is owning responsibility for referral screening practices, and if their data is sufficient.
  4. Determine which systems or solutions are capturing referral data (billing systems, EMR/EHRs, contact database, A/P, etc).
  5. Establish unique identifiers for referring providers (SSN, NPI, TIN, EIN)
  6. Monitor referring individuals with associated data and eligibility status

Considerations for Referring Provider Monitoring

  • Does your list of non-employed physicians change routinely?
  • Are you adding and/or removing physicians from your data sources often?
  • Do you have enough information to conduct/complete exclusion monitoring?
  • How often do you monitor referring providers (before a claim is submitted, monthly, quarterly, annually)?

Non-employed Physician Screening and Monitoring

Provider and physician monitoring must become a priority for protecting your organization’s compliance standards of participation in federal healthcare programs. There are many populations of healthcare providers who completely rely on these standard referral programs as their care delivery methods such as laboratories, imaging centers, durable medical equipment suppliers, pharmacies, and more. According to HHS OIG, “to avoid liability, providers should ensure, at the point of service, that the ordering or prescribing physician is not excluded(emphasis added).”

Depending on the setting, non-employed healthcare populations such as a referring, ordering or prescribing provider, can vary in definition and degree of interoperability. In the post-acute space, attending physicians occupy a large part of normal operations for care centers and health systems. How you are controlling and monitoring external networks is critical, and unfortunately, it is challenging to do this manually or exclusively with government data resources. Most likely, you’ll need a data partner or software solution to help get the job done! 

Here are a few things to keep in mind when you are evaluating your monitoring process or workflow for non-employed physicians and avoiding fines, penalties, and excluded parties: 

  • Does the physician have a current license without restrictions?
  • Does the physician have the proper credentials?  
  • Is the physician excluded from participating in Medicare/Medicaid or other sources? 
  • Does the physician have a valid DEA registration in order to prescribe?

HHS OIG states that “some excluded practitioners will have valid licenses or Drug Enforcement Agency (DEA) numbers. Therefore, it is important not to assume that because a prescription contains a valid license number or DEA number, the practitioner is not excluded.” 


Automating Referring Physician and Provider Screening

When it comes to upholding the integrity of federal healthcare programs, the government publishes several databases and online directories to aid healthcare organizations in verifying eligibility and to provide transparency for the public to each provider’s information. Providers can refer to the CMS Order and Referring List to search a provider’s NPI number to identify enrollment status in the NPPES Registry. To confirm exclusions status, providers can also reference the OIG List of Excluded Individuals and Entities (LEIE)

Unfortunately, these directories must contend with inefficient reporting from each state, as well as confidentiality requirements. Determining provider eligibility can be difficult without enhanced tools and datasets to help aggregate the right information and build a consistent provider and healthcare organization profile. Manually compiling this disparate data and unique identifiers can waste time and resources, and exposes healthcare organizations to undue risk.

Healthcare professionals rely on automated physician monitoring solutions and augmented data from third-party technology partners to help them feel confident with each referral. Our team is happy to assist organizations in identifying potential risk and reimbursement concerns before any issues occur. 

The Value of Smarter NPI Data

Although an NPI is a common healthcare identifier and technically only provides basic information like Name, NPI, Address, Phone, Taxonomy, it has powerful potential as a unique identifier. The National Provider Identifier (NPI) can be a game-changer as it works to supplement data for other helpful and even critical healthcare functions in compliance, human resources, credentialing, procurement, claims processing, and more.

NPI Healthcare Unique Identifiers

There are many different types of NPI lookup software online, but many of these low-cost options only scratch the surface of the versatility of NPI validation and verification. We believe that many processes can be improved by leveraging NPI data with other unique identifiers across various online registries. 

Our solutions organize these data points to create a more comprehensive profile for physicians, healthcare organizations, and more. We combine CMS enrollment information with exclusion, sanction, and license data to present you important referral information in order to make the best compliance decisions. 


Healthcare Database Screening and Exclusions Monitoring for Provider Referrals

Completing employee and organization profiles with augmented data (like NPI and SSN) helps create a smarter exclusion monitoring program for your organization to eliminate errors and insufficient information gaps. Using both the NPI and screening against all exclusion lists (OIG LEIE, SAM.gov, all state Medicaid lists) is a great step in identifying where to address potential disqualifications of services provided by healthcare staff, vendors, volunteers, referrals, business associates, and more.

Help keep your company and patients safe with smarter NPI verification and exclusions screening software. To take a deeper dive into this topic, check out our on-demand recording of a webinar replay – How to Effectively Screen Your Referring Physician Network Using NPI. 


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ProviderTrust Healthcare License Monitoring Essential Guide
ProviderTrust Mike Rosen Cofounder

Written by Michael Rosen, Esq. ProviderTrust Co-Founder, mrosen@providertrust.com

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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