Exclusion Monitoring: The Relationship Between the OIG and the System for Awards Management (SAM)
When looking into the OIG exclusion monitoring recommendations, you’ve likely noticed that the OIG recommends monitoring sanction and exclusion lists that seem to fall outside of the healthcare field. For example, the System for Awards Management (SAM) program houses sanctions/exclusion lists for many federal agencies from the Department of Justice, the Environmental Protection Agency, and many more.
Why OIG Recommends Monitoring Non-Healthcare Sanction and Exclusion Lists
At first glance, it may be hard to reconcile why the OIG recommends monitoring SAM when many federal agencies aren’t tied directly to the healthcare field. However, the OIG exclusion monitoring recommendations seek to add protection to everyday citizens on multiple levels, one of those levels being to try and keep known bad actors in other fields and industries away from healthcare.
To examine how the OIG exclusion monitoring recommendations work on a few different levels to protect every day individuals, we can take a look at a couple recent pieces of news from the OIG Enforcement Actions page.
Recent OIG Enforcement Actions
The first enforcement action that we can take a look at is the Department of Defense filed a complaint against six health plans participating in the Uniformed Services Family Health Plan (USFHP) program. The complaint from the DOD alleges that defendants violated the False Claims Act by knowingly retaining erroneously inflated payments for healthcare services the health plans contracted to provide to retired military members and their families. Through the USFHP program, the DOD pays the plans capitated rates to provide healthcare services to their enrollees. According to the complaint from the DOD, in June 2012, the plans learned of calculation errors that had inflated the rates they had been paid in prior years, nevertheless, the plans took steps to conceal the overpayments from the government and continued submitting invoices at the inflated payment rates.
From the way the press release from the Department of Justice reads, the issue here is one of fraud between the aforementioned health plan and the Department of Defense, which might initially obfuscate the main way this lawsuit ultimately helps protect everyday citizens. However, the DOD budget is derived from the taxes of United States citizens. By knowingly defrauding the DOD, USFHP has essentially defrauded the American public by knowingly having some of our tax dollars go towards their false claims. While this may seem pedantic at a certain level, it serves as a good illustration of how the OIG exclusion recommendations seek to protect the public by handing down exclusions to bad actors throughout the field of healthcare, not just doctors and hospitals.
The next enforcement action takes a look at a lawsuit that is completely removed from the healthcare field. This past month a former Navy civilian employee and former executive were indicted in a bribery scheme involving over $100 million in government contracts. The main reason we are mentioning it here is to illustrate that if the OIG exclusion monitoring recommendations only recommended checking the OIG exclusion list each month, bad actors from outside the healthcare industry could have the chance to slip into the industry without many people being the wiser to their history of bribery and fraud. The OIG exclusion monitoring recommendations include searching SAM to ensure these bad actors don’t slip into the healthcare system to prey on everyday citizens and ultimately waste taxpayer dollars on their own designs.
Ensuring Compliance with OIG Exclusion Monitoring
To ensure your program is meeting OIG recommendations, please check out EPStaffCheck.