Exclusion Screening: The Crucial Question of “Who?”
In the realm of healthcare compliance, every organization knows the importance of exclusion screening. The Office of Inspector General (OIG) has made it abundantly clear that employing or contracting with an excluded individual or entity can lead to devastating financial and legal consequences. However, a common misconception is that this process only applies to direct patient care providers, like doctors and nurses. The reality is far broader, and failing to screen all relevant parties can leave a healthcare organization—from a small clinic in Rossville, Maryland, to a large hospital system—dangerously exposed.
Why “Who” Matters: The Broad Scope of the OIG’s Rule
The OIG’s policy is clear: no federal healthcare program payments may be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. The key is the term “furnished.” The OIG interprets this broadly to include not only direct patient care but also a wide array of administrative and support services. If an excluded individual’s activities contribute, even indirectly, to an item or service that is billed to a federal program, the claim can be considered fraudulent, and the organization can face penalties.
Who Must Be Screened?
To be fully compliant, healthcare organizations must cast a wide net and screen the following individuals and entities:
- All Employees: This includes every person on the payroll, regardless of their role. A front desk clerk who processes patient forms, a billing specialist who submits claims, an IT professional who maintains patient data, and even a janitor working in a facility where services are provided—all must be screened. An excluded person’s presence in any role that contributes to a billed service is a violation.
- All Contractors and Subcontractors: Many healthcare organizations rely on a network of external partners. It’s not enough to screen your own employees. You must also screen:
- Temp Staff: Any temporary nurses, therapists, or administrative staff provided by a staffing agency must be screened before they begin work.
- Billing and Coding Companies: The OIG has a strong focus on billing fraud, and any company you outsource your billing to must be screened. The individuals working on your account should also be screened.
- Consultants: An excluded consultant who provides advice on strategic planning or operations can taint the entire organization.
- IT Vendors: A vendor providing electronic health record (EHR) services, data storage, or cybersecurity for your systems must be screened, as their services are directly tied to the delivery of healthcare.
- Ancillary Service Providers: This includes ambulance drivers, home health aides, and durable medical equipment (DME) delivery personnel.
- Owners, Officers, and Managing Employees: The OIG can and will hold leadership accountable. All owners, executives, board members, and anyone with a managing role must be screened. The presence of an excluded individual in a leadership position can be a basis for a permissive exclusion of the entire organization.
- Ordering, Referring, and Prescribing Providers: Even if a provider doesn’t work directly for your organization, if they order, refer, or prescribe services that your organization bills to a federal healthcare program, you must screen them. For example, a specialist who refers a patient to your physical therapy center must be screened.
How Often to Screen
The OIG’s List of Excluded Individuals/Entities (LEIE) and state exclusion lists are updated regularly. A single screening at the time of hire is not sufficient. To be truly compliant, organizations must screen all individuals and entities prior to hiring or contracting and then on a monthly basis thereafter. This proactive approach ensures that a newly excluded individual is promptly identified, preventing a cascade of non-compliant claims.
Conclusion
Exclusion screening is a continuous process that must encompass every person and entity that contributes to services reimbursed by federal healthcare programs. By broadening the scope of “who” to be screened, from the CEO to the contracted janitor, healthcare organizations can effectively mitigate their risk, protect their financial integrity, and uphold the highest standards of compliance.