No matter the size or specialty, any healthcare organization that receives federal funding must perform exclusion screening. The scope of screening, however, should be tailored to the organization type, ensuring all high-risk areas are covered. While the core principle—checking against the OIG’s List of Excluded Individuals/Entities (LEIE) and other federal and state lists—remains constant, the key is knowing who to screen and why.
Hospitals and Large Health Systems
Hospitals face the most complex screening requirements due to their size and variety of services. They must screen a vast range of individuals and entities.
- Clinical Staff: All physicians, nurses, therapists, and other licensed healthcare professionals.
- Support Staff: From administrative and billing personnel to IT staff, janitorial services, and food service workers. If their work contributes in any way to a billable service, they must be screened.
- Contractors and Vendors: This is a major area of risk. Hospitals should screen third-party billing companies, medical equipment suppliers, consultants, and even temporary staffing agencies.
For large organizations, continuous, automated screening is the only way to effectively manage the sheer volume of people and entities they work with.
Nursing Homes and Long-Term Care Facilities
Nursing homes have a unique set of risks, with a heavy emphasis on patient safety and quality of care. The OIG has a specific focus on patient abuse and neglect, making screening for these offenses paramount.
- All Employees: Every employee, from certified nursing assistants (CNAs) and licensed practical nurses (LPNs) to administrative and dietary staff, must be screened. A nursing home can face severe penalties if an excluded individual is found to be providing care, even if they aren’t directly billing for it.
- Third-Party Providers: Many nursing homes use contractors for services like physical therapy, pharmacy services, and dietary needs. These companies and their staff must also be screened.
Home Health Agencies
Home health agencies are a frequent target of fraud investigations, as their services are provided with limited supervision. This makes thorough screening essential to ensure providers are not billing for medically unnecessary services or services that were never performed.
- Direct Care Providers: All home health aides, nurses, and therapists must be screened. Since these individuals often work independently, their integrity and compliance are crucial.
- Back-Office Staff: Employees involved in billing, scheduling, and patient intake must be screened to prevent fraudulent claims.
- Referring Providers: Home health agencies must also screen physicians and other providers who refer patients for their services, as kickback schemes for referrals are a common form of fraud.
Durable Medical Equipment (DME) Suppliers
DME suppliers must screen everyone who plays a role in their business, from sales to delivery. A common fraud scheme involves using excluded individuals to engage in illegal telemarketing or billing for equipment that was never delivered.
- Sales and Marketing Staff: Since this team often interacts with patients and referral sources, they must be screened to prevent kickbacks and other fraudulent activities.
- Delivery and Support Personnel: Anyone who delivers, sets up, or services the equipment must be screened. The OIG considers their services “furnished” under the law.
- Executive Leadership: The OIG holds owners and executives personally liable for compliance failures.
All Organizations Must Screen:
While the specifics may vary, there’s a common thread. All healthcare organizations must:
- Screen all employees and contractors before they start work.
- Perform monthly rescreening against the OIG’s LEIE, the System for Award Management (SAM), and all relevant state Medicaid exclusion lists.
- Document everything to prove due diligence. A robust exclusion screening program is not just about avoiding penalties; it’s about protecting patients and the integrity of the healthcare system.