Protecting Your Practice: The Essentials of OIG Screening and CMS Open Payments

When bringing on a new employee, having a resume, and calling references, is not enough to hire someone in the healthcare industry. Government programs such as Medicare and Medicaid provide the majority of funding for the healthcare industry; this creates many rules for who can work in the industry.

When managing a medical practice or healthcare organization, you must protect your business by knowing everything there is to know about compliance and regulations. This includes understanding the Office of Inspector General's role with regard to compliance and financial transparency.

To help you understand compliance with the Office of Inspector General (OIG), we provide information about OIG checks, OIG screenings, OIG excluded individuals, and CMS Open Payments.

What is an OIG Check?

An OIG check is a procedure used to verify if a prospective or current worker is listed on the Office of Inspector General's (OIG) List of Excluded Individuals Entities. The OIG is part of the Department of Health and Human Services and is responsible for battling against the waste, fraud, and abuse that occurs within Medicare, Medicaid, and other HHS programs. When someone is included in the LEIE, the individual has been banned from participating in any federal healthcare plan. Therefore, if you bill Medicare or Medicaid for services provided by an un-verified employee, you are committing fraud.

Continuously Screening With the OIG is Important

Most organizations check the LEIE only when hiring a new employee. The OIG updates their Exclusion List OIG every month. It is important to note that an employee cleared in January may become excluded in February due to a defaulted student loan, revoked license or felony conviction. Continuous Screening with the OIG is essential; best practices suggest compliance officers run their entire employee, vendor and contractor roster against the OIG database at least once monthly. Automated screening software is now a common tool in the industry to ensure names are not missed in the screening process.

When hiring a person who appears on the OIG Exclusion List, this would represent a potential serious consequence for an employer. Under the Civil Monetary Penalty Law, if an Excluded person has furnished services while employed and been reimbursed by Medicare, it would subject an employer to a possible monetary penalty of $20,000 per item or service billed. Additionally, the employer may be liable to pay three times the dollar amount billed by the Excluded person for the same item or service.

In addition to financial liability, there would be other serious consequences for an employer if they employed an individual who is on the OIG Exclusion List. Hiring an individual on the Exclusion List would damage an employer's Good Will and Reputation. Employers need to perform proper due diligence regarding who they employ and patients expect healthcare organizations to conduct such due diligence. An employer's failure to conduct due diligence when hiring will result in a tremendous loss of years of trust built up between an organization and its community.

In the United States, the Office of Inspector General (OIG) conducts background checks for criminal history as well as any potential administrative disqualifications. On the other hand, the Centers for Medicare and Medicaid Services (CMS) collects information on the financial transactions between drug/device manufacturers and healthcare providers, via the CMS Open Payments program, also known as the "Sunshine Act".

The information collected and reported through CMS’s Open Payment database is available for all to see. So, if a patient wants to find out about any payments made by drug companies to their physician (i.e., for consulting, research, or travel), they can find this information online. Healthcare organizations can use this data to monitor potential conflicts of interest, thereby ensuring that the quality of medical care provided is based on what is in the best interest of the patient and not on any financial incentive(s) from a pharmaceutical device manufacturer.

Conclusion

compliance is an ongoing process that requires commitment. Your organisation can operate confidently when it utilises a consistent OIG Check process, conducts monthly OIG Screens, prevents OIG Excluded Hires, and monitors CMS Open Payments. Not only do these processes help protect your company's financial health, but they protect patients who depend on your organisation to provide them with the highest standard of care without prejudice.