Over a Billion Reasons to Consider Monthly Exclusion Monitoring in 2018

2018 has begun, and naturally, we are all thinking of ways to make it better than the previous year. For those of us in the compliance world, that means continuing to reduce the risks to our organizations by having a high-quality compliance focus. Well, here are $8,882,48,845 reasons to start with OIG exclusion list monitoring. 

You read that right – $8.8B dollars of possible fines all residing in ONE federal exclusion database. The OIG List of Excluded Individuals and Entities (LEIE) is the Department of Health Human Services, Office of the Inspector General’s publicly available exclusion dataset. As of December 31, 2017, there are 68,732 individuals and/or entities that are actively excluded. An exclusion is an administrative remedy that the OIG can impose upon an individual and/or entity, pursuant to Sections 1128 and 1156 of the Social Security Act. According to OIG, anyone who hires or contracts with an excluded individual or entity is subject to civil monetary penalties (CMP).

In 2017, the average CMP imposed was $129,233 per individual or entity. The total CMP’s issued for those self-disclosed exclusions was $3,491,978. When you add other civil fines and penalties imposed under affirmative exclusions and those under a CIA, the total fines for exclusion related penalties totaled $5,298,000+ in 2017. However, 100% of these CMP’s were avoidable if the employer had conducted monthly OIG LEIE exclusion monitoring.

2017 OIG Exclusions and Penalties

– As of December 31, 2017, there are 68,732 active excluded parties on the OIG LEIE.

– In 2017, OIG imposed $3,5000,000 in CMP fines against employers or contractors for hiring or contracting with an excluded provider.

– The average OIG CMP for a provider who self-disclosed that it hired or contracted with an excluded individual or entity was $129,233.

– If a provider self-discloses to OIG, the fine multiplier can be reduced to 1.5x. So, if these were not self-disclosed, the CMP could have been over $7M.

– A provider or entity can be excluded or debarred by SAM.gov or any one of 41 State Medicaid exclusion authorities. In fact, there are a total of 200,088 excluded individuals or entities for a healthcare. related infraction between the OIG-LEIE, SAM.gov and the 41 state Medicaid exclusion lists as of in 2017.  

– There were 5 exclusions of individuals whose company was under a Corporate Integrity Agreement. Those 5 CIA reported exclusions averaged $261,000 per individual or entity.

– 100% of these CMP fines are avoidable if you conduct federal and state exclusion monitoring each month.

So, with almost 70,000 excluded OIG individuals or entities, and an average fine of $129,000 per individual (for self-disclosures), if all of these excluded parties were hired or being contracted within healthcare, the fines would exceed $8.8 billion. But just one individual or entity, on average could cost your organization over $129,000 in civil monetary fines if you self-disclose it to OIG.

Ask yourself:  Can you afford to risk a $129,000 per employee fine for hiring, employing or contracting with an excluded party in 2018? Then ask yourself, how you would feel if you had to explain to management that 100% of this exposure was avoidable with low-cost monthly exclusion monitoring of the OIG-LEIE?

OIG LEIE Exclusion Facts

1. 90% of the excluded parties on the LEIE are individuals and 10% are entities.
2. 48% of exclusions originally stemmed from a license infraction at a state licensing board.
3. Approximately 3,000+ new names are added each year.
4. There are two types of exclusions; mandatory and permissive.
5. Once the exclusion term is over, the provider must apply for reinstatement, it is not automatic.
6. One of the permissive authorities for exclusion includes a default on a federal HEAL Student Loan.
7. Some exclusions have been imposed for 50+ years.
8. Not all OIG LEIE records contain a Social Security Number of the individual.
9. Approximately only 5% of OIG LEIE records contain an NPI as an identifier.
10. An excluded individual cannot have a management or administrative role in a non-excluded company.

At ProviderTrust, we work hard to provide a clear picture of how state Medicaid lists and federal records are in sync. Our data team combines vast amounts of stats to aid in understanding the gaps of exclusion records. In our quarterly Compliance Healthcare Index Report (CHIRP), we break down the relationship between each state’s exclusions and federal lists.

For example, did you know that of the 62,944 state exclusions, it takes, on average 169 days for that exclusion to reach the OIG-LEIE, if it is reported at all to the OIG-LEIE? With volume and accuracy discrepancies this conflicting, it can be considered best practice to add state Medicaid exclusion list monitoring to your OIG-LEIE and SAM.gov monthly routine. In this way, your team has the ability to capture all possible state and federal exclusions in a timely fashion.

Summary

The OIG has made it both clear and easy to search its publicly available OIG List of Excluded Individuals or Entities. The power of OIG to issue fines and penalties (CMP) against companies that hire or contract with an excluded person or entity is mighty. The fines are costly, yet 100% avoidable. As you are reviewing your compliance plan for 2018, be sure to revisit how you are conducting exclusion monitoring and ensure that it is done monthly. At a minimum, your organization should be checking the OIG-LEIE monthly on all employees and contractors. It is best practice to search at the time of a referral from a non-employed physician for exclusions. For the most current information on this subject, you should familiarize or re-familiarize yourself with the OIG Advisory.

Any questions on exclusion monitoring? We’d be happy to help! Leave us a comment or send us a private message.

Written by Michael Rosen, ESQ