As a practice that accepts Medicare and Medicaid, you are required to know the exemption status of your candidates, employees, and vendors. Failure to do so can have dire consequences, such as significant fines, loss of your ability to bill Medicare and Medicaid, and even jail time (in extreme cases).
Even an innocent mistake can land you in serious hot water with the Office of the Inspector General (OIG), the agency that polices excluded individuals. Violation sanctions can be as high as $10,000 per service item claimed – which can quickly add up to hundreds of thousands of dollars in penalties.
The good news is that there are resources available that can help you avoid exclusion errors, maintain your billing status with Medicare and Medicaid, and avoid costly violation penalties.
Exclusion List is the Answer
When the OIG excludes individuals or vendors from being able to bill Medicare and Medicaid services due to fraud, abuse, or other violations, they are included on the List of Excluded Individuals and Entities (LEIE).
The LEIE can help you avoid accidentally hiring an employee or contracting with a vendor that the OIG has designated as excluded from billing Medicare and Medicaid. Without it your practice can be hit with significant enforcement actions, or worst, end up on the exclusion list, unable to be reimbursed for seeing Medicare patients.
In a February 2022 case, a Connecticut psychiatric practice and its owner were ordered to pay $310,000 for employing an excluded physician. The practice was also convicted of conspiracy to commit healthcare fraud and banned from all federal healthcare programs (including being able to bill Medicare).
The psychiatric practice employed the excluded physician for more than five years, billing federal healthcare programs such as Medicare, Medicaid, TRICARE, and the Railroad Retirement Medicare Program for services provided. A little bit of prevention would have gone a long way toward protecting this practice from paying out hundreds of thousands of dollars in fines.
The OIG has issued penalties of more than $27 million against healthcare organizations who claimed federal reimbursement for services provided by Medicare excluded individuals. The good news is that you can avoid making this mistake with regularly scheduled LEIE checks.
Using Exclusion Lists
The best way to protect your practice from inadvertently hiring an employee or contractor that is excluded from billing Medicare is to check the OIG’s exclusion list (LEIE) regularly. This database includes more than 60,000 people, entities, and vendors who are excluded from federal healthcare programs and is updated monthly.
Additionally, if your practice is reimbursed with federal program dollars and requires Government Services Administration (GSA) approval, you must also check the SAM.GOV Excluded Parties List System (EPLS). The people and organizations on this list are debarred, sanctioned, or otherwise excluded from doing business under a federal contract.
Action for Identified Exclusions
To protect your practice from OIG penalties, you must take action immediately if you recognize a name on either government list (LEIE or EPLS). The action you take is dependent on the circumstances.
- Pre-Hire Check: Discovering that someone you’re planning to hire or contract with is on either exclusion list means your course of action is easy. You simply don’t hire them. Period.
. - Existing Employee/Contractor: Should you find that an employee or vendor pops up onto either exclusion list after you’re already working with them, it’s not so easy. If this happens, you must begin the self-disclosure process Self-disclosure allows your practice to avoid any costs and disruptions that may be associated with investigations or litigation. Unfortunately, you may still face penalties. However, reporting the discovery yourself is far less damaging than if the OIG identifies the issue first.
Both exclusion lists (LEIE and EPLS) are kept current with regular updates where new people are added, and others removed. Accordingly, just checking the status of a potential employee or vendor at the beginning of your relationship isn’t enough.
Bottom line is that it’s your responsibility to know if someone you have on staff or contract with is considered excluded from billing Medicare or Medicaid. Adding a monthly reminder can be a great way to remember to check these lists regularly.
Keep your practice compliant with Healthcare Training Leader’s online training, Avoid Simple Employee Exemption Mistakes That Can Get You Sued. In this 60-minute training, wage and hour compliance attorney, Michelle Anderson, JD, walks you through the most confusing aspects of properly paying and classifying your employees that could get you into trouble. Watch this important online training today.
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