What is the Difference Between a Sanction and an Exclusion?

Sanction Screening: A deep dive

What is a Healthcare Sanction?

A healthcare sanction is the result of an administrative action taken against an individual or entity found to be in violation of an administrative rule, civil law, or criminal offense by a state professional licensure board. Such sanctions can be attributed to a restriction placed upon the license and can include a revocation of the license. These are also called disciplinary actions against the license. In order to locate a sanction or disciplinary action on a license, a search of the state professional licensing board minutes or actions must occur.

What is the Difference Between a Sanction and an Exclusion?

Because the HHS-OIG and federal databases refer to exclusions as “sanctions”, there is often confusion amongst healthcare and compliance professionals because the two terms are incorrectly used interchangeably.

A sanction (also referred to as a medical sanction) is the result of a disciplinary action taken against an individual’s license by a state administrative board- commonly by a state licensing board. Sanctions can be imposed for many reasons but are primarily the result of patient abuse, criminal convictions related to diversion of controlled substances, or healthcare fraud.

An exclusion, however, is the result of an extreme sanction which is issued by the HHS-OIG (Office of Inspector General). Exclusions are typically reserved for those who pose a high risk to patients or a program’s integrity.

Prior to a healthcare professional receiving a sanction, there has been a due process hearing at the license or disciplinary board and/or the excluding agency. Thus, the individual has an opportunity to present his/her case. Upon the issuance of a penalty, sanction, or disciplinary action, an individual’s license may be restricted, revoked, suspended, or other measures placed upon it. This process can take months and even years to progress.

What are the Consequences of a Healthcare Sanction?

A sanction from a healthcare disciplinary or licensing board can have significant consequences. The most severe is becoming excluded.

Once added to the OIG’s LEIE (List of Excluded Individuals and Entities), these individuals or entities are prohibited from participation in federal or state healthcare programs and cannot receive federally funded reimbursement from programs like the Centers for Medicare and Medicaid Services (CMS). Additionally, the exclusion can also lead to GSA debarment and/or a state(s) exclusion, too.

Once an individual or entity is excluded in one state, he/she/it is considered excluded in all states (Section 6501 Affordable Care Act). Under the Affordable Care Act, an individual or entity/vendor excluded in one state is not permitted to participate in federal healthcare funds in all other states. A person or entity can be excluded by a federal agency (HHS OIG) or by a state Medicaid agency.

40% of the time, excluded providers on the OIG’s List of Excluded Individuals and Entities are derived from their license being sanctioned or revoked.

How can Healthcare Sanctions Impact Your Organization?

If you, the employer, submit a claim for and/or receive federal healthcare reimbursements either directly or indirectly for that individual or entity, your organization is subject to civil fines and monetary penalties.

A healthcare organization cannot purchase goods or services from an entity or vendor that is excluded. The OIG mandates that healthcare organizations do not hire or do business with “excluded or sanctioned” individuals or entities/vendors.

How to Identify Sanctions with Exclusion List Monitoring

According to the OIG, CMS Guidelines, and State Medicaid Bulletins or Directives, it is the responsibility of the employer to conduct monthly exclusion monitoring. A sanction against an individual’s license can be an early indicator of an impending OIG or State exclusion depending on the type of infraction, the sanction imposed and/or the conviction of certain felonies.

There are 43 State exclusion or terminated provider lists and 2 federal exclusion lists that should be checked each month for your employees, contractors, and third-party entities, in addition to monthly OIG exclusion monitoring.

Exclusion Monitoring Solutions

A manual sanction screening process can leave HR and Compliance teams left with what seems to be an insurmountable task of constant monitoring and updating their information.

Here are just a few examples of what could happen within your healthcare data and employee population when a sanction occurs but would be hard to detect.

  • Delays or lags of time of many months between when an individual is sanctioned on the state level to when that offense is actually reported on the federal level. Thus, making it possible that one can have a sanction on the state level, but not show up on a federal list.
  • Similarly, there have been situations where sanction data reported to licensing boards have not been properly reported to the federal and state databases.
  • To avoid and conceal past records, individuals have altered names or used maiden names, changed addresses, and even gone as far as falsifying sensitive data such as social security numbers.

There are new technologies and sanction screening software that can alleviate the headache by aggregating all of these datasets, allowing you to avoid the pitfalls of delayed reporting and intentional provider identity concealment.

Reimagine your exclusion monitoring.

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