Deeper Than the Headlines: Exclusion Checks

Is your compliance program diligently performing its exclusions’ checks against sanctioned individuals?  Does it seem like a mundane task that hardly ever turns up an excluded individual? Though that may be true, just missing one excluded individual could mean a big headache and financial fines for your organization. Let’s review some of the settlements that have resulted in this year from organization’s who employed or contracted with excluded individuals and pay attention to the variety of jobs or roles these individuals were working in (I’ve bolded and underlined the job title for ease of identification):

08-24-2018

St. Mary's Health System (St. Mary's), Lewiston, Maine, entered into a $68,497.32 settlement agreement with OIG. The settlement agreement resolves allegations that St. Mary's employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a call center patient scheduler, provided items and services to St. Mary's patients that were billed to Federal health care programs.

08-02-2018

Ireland Health Care Center, Inc. d/b/a Singleton Health Care Center (SHCC), Cleveland, Ohio, entered into a $45,735.42 settlement agreement with OIG. The settlement agreement resolves allegations that SHCC employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a licensed practical nurse, provided items or services to SHCC's patients that were billed to Federal health care programs.

08-02-2018

Gerrish Chiropractic Center (GCC), Bar Harbor, Maine, entered into a $7,019.10 settlement agreement with OIG. The settlement agreement resolves allegations that GCC employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, an office manager and chiropractic assistant, provided items or services to GCC's patients that were billed to Federal health care programs.

07-02-2018

William H. Newman, M.D., and Allergy & Asthma Specialists of Northern Vermont, P.C. (collectively, "Dr. Newman"), entered into a $61,142.96 settlement agreement with OIG. The settlement agreement resolves allegations that Dr. Newman employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a registered nurse, provided items or services to Dr. Newman's patients that were billed to Federal health care programs.

05-17-2018

Immediate Home Care (IHC) in Bensalem, Pennsylvania, entered into a $189,445.68 settlement agreement with OIG. The settlement agreement resolves allegations that IHC employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a home health nurse, provided items or services to IHC's patients that were billed to Federal health care programs.

05-04-2018

Alameda Health System (AHS), California, entered into a $257,874 settlement agreement with OIG. The settlement agreement resolves allegations that AHS employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, an eligibility clerk, provided items or services to AHS's patients that were paid for by Federal health care programs.

03-26-2018

Community Care, Inc. (CCI), located in Brookfield, Wisconsin, entered into a $208,585.20 settlement agreement with OIG. The settlement agreement resolves allegations that CCI, a care management organization, contracted with an individual who was excluded from participating in any Federal health care programs. OIG's investigation revealed that the excluded individual provided for residential items or services to CCI's patients that were billed to Federal health care programs.

03-27-2018

ASAP Home Nurses, Inc. (ASAP), located in Wadsworth, Ohio, entered into an $11,406.26 settlement agreement with OIG. The settlement agreement resolves allegations that ASAP employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a state tested nurse aide, provided items or services to ASAP's patients that were billed to Federal health care programs.

3-21-2018

Pharmex Pharmacy, LLC, and Israel Weber (collectively, "Pharmex"), Lakewood, New Jersey, entered into a $314,205.76 settlement agreement with OIG. The settlement agreement resolves allegations that Pharmex employed an individual who was excluded from participating in any Federal health care programs. OIG's investigation revealed that the excluded pharmacist provided items or services to Pharmex patients that were billed to Federal health care programs.

02-16-2018

Arkansas Convalescent Center (ACC), Pine Bluff, Arkansas, entered into a $189,805.55 settlement agreement with OIG. The settlement agreement resolves allegations that ACC employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a licensed practical nurse, provided items and services to ACC patients that were billed to Federal health care programs.

02-13-2018

Southwest Trinity Management, LLC (STM), entered into a $141,986.36 settlement agreement with OIG. The settlement agreement resolves allegations that STM, through a skilled nursing facility it owns and manages in Oklahoma City, Oklahoma, employed an individual who was excluded from participating in any Federal health care program. OIG's investigation revealed that the excluded individual, a licensed practical nurse, provided items or services that were billed to Federal health care programs.

To avoid Civil Monetary Penalty, health care entities need to routinely check for excluded individuals to ensure that new hires and current employees are not on the excluded list. The primary effect of an excluded individual is that no payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This includes Medicare, Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).

Spending a little time, money and effort up front can help avoid these significant financial penalties after the fact.