To keep federal resources from being abused by certain individuals or entities, the Office of Inspector General (OIG) has created the List of Excluded Individuals/Entities (LEIE). This list contains the names of people and groups that have been excluded from participating in healthcare programs that benefit directly or indirectly from government funds. The exclusion or sanction can be caused by a proven history of committing fraud, abusing medical supplies such as medicine and other medical equipment, and exploiting resources that could have otherwise been used for providing healthcare to patients.
The OIG requires health organizations to make sure that they are not affiliated with any individual or entity that is included in the LEIE. By working with an excluded person or group, a healthcare organization faces serious consequences that could cost up to millions of dollars in heavy penalties, depending on the amount of resources successfully claimed by the excluded person or group.
Protecting Healthcare Organizations thru Sanction Screening
Healthcare organizations are required by the OIG to perform monthly sanction screenings on individuals that have established ties with them. During a sanction screening, employees and contractors are checked to see if their name is included in the LEIE. Once a match has been confirmed, the healthcare organization must do the following:
- Terminate business with the excluded individual or entity
- Assess the amount of resources that were reimbursed in the name of the excluded person or entity
- Send a letter of disclosure to the OIG regarding the discovery of a LEIE match
- Advise the excluded individual or entity to refrain from referring any more patients to the organization and/or getting involved in other kinds of healthcare programs.
- Notify patients who have been involved with the excluded individual or entity during the time the exclusion is in effect
While sanction screenings are important, many health organizers fail to carry them out on a monthly basis. As a result, some excluded individuals may get past the process and have the opportunity to keep siphoning off healthcare resources for their own gain. On the other hand, organizations who try to be more meticulous with their screening process may find themselves spending too much time and effort on conducting the screenings. This is especially true for large organizations that have hundreds of employees and contractors.
Automating the Screening Process
Health organizers that struggle with regular sanction screenings will be glad to know that there are different tools available to help make the process more manageable and the results more accurate. A great example of these tools would be powerful exclusion screening systems that are designed to automate most of the screening process.
Automating the screening provides a number of key benefits that any health organization will be glad to have, such as:
- Automatic Updates – The best screening system always uses the most recent version of the LEIE to ensure that all information is accurate by the time of screening. Other exclusion list databases may also be used when performing searches for more thorough screenings. The screening service can be prompted as soon as the OIG updates the LEIE.
- Thorough Screening – By using a complex series of algorithms, automated screening tools may be able to analyze the chances of an individual or entity being included in the LEIE, even if they do not have a successful match in the database. The service can be programmed to comb through various databases to accurately match individuals and entities. Furthermore, the software can also use an individual’s social security number or cross-reference pertinent details to verify a match. These functions help track down certain individuals that may be using false information in order to avoid detection.
- Automatic Notification – Should there be a match, the software can immediately send a series of notifications to the healthcare organization’s HR department. The HR personnel, in turn, can take action by ordering a background check on the individual or vendor in question in order to confirm or verify the exclusion. The automated process helps the company conserve resources and avoid unnecessary background checks, while the automated notification ensures that fraud and abuse is stopped as soon as possible.
Augmenting Automation with Peer Review
Although automated sanction screening already makes a lot of difference when it comes to the speed and accuracy of the process, there’s always room for improvement. By combining the strengths of automated screening tools and peer review, healthcare organizations can expect a more powerful sanction screening system.
Some may think that adding more human elements to an already automated system is kind of defeating the purpose of the software, but peer review actually complements advanced exclusion screening tools. Excluded people are more likely to be detected, and individuals that may warrant being in the LEIE can also be spotted before any harm is done. How does peer review make it possible?
Once the software is done sifting through various databases to gather resources that will help confirm or clear a potential match, the result of the search will be sent to an analyst. The analyst will then review the sources and supporting documents, adding a human element to the screening process. After that, the analyst will ping the company’s HR personnel and inform them that one of their employees or vendors may have been excluded. The analyst will also offer recommendations, like doing a more in-depth background search, to confirm if the sanctioned individual and your employee refer to one and the same person.
In short, giving each search an “eyes on” treatment will help build a compelling case when pursuing a potential match or clearing the identity of an individual. By conducting a quick automated screening and subjecting its result to discerning eyes, Emptech ensures a more thorough search and matching process.
Accurate automated screening solutions and peer review play a crucial role in helping healthcare organizations avoid harsh penalties. And by learning how to take advantage of the two aspects of sanction screening, healthcare organizations will be able to properly do their part in making sure that the resources meant for the patients will always go to the patients.