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.

How should you verify a possible match that comes up during your monthly compliance monitoring? This is a question that we often get phone calls and support tickets about here at Valenz.

First off, a matching, or close matching, name alone is not enough to determine whether the person you are searching for and the possible match that appeared are the same individual. Claiming a searched party is a confirmed match on name alone could expose your organization to FCRA claims and further issues.

Further verification is an important step in the compliance monitoring process as it allows you to be sure of whether a possible match is a full match with verifiable information like date of birth and Social Security Number.

How to Verify a Possible Match

When a possible match does appear during a search, they can sometimes be verified with information that you already have available or can easily retrieve if needed. If you are presented with a possible match during your monthly compliance monitoring, following these steps can ensure that you’re verifying them the correct way:

• Check for verifiable information in the record details. For example, does the possible result give a DOB for the sanctioned/excluded individual? If not, does it give a middle name? If yes to either of those, and the information does not match that of the searched party, that is a good indication that there is not a positive match.
• If further information is not given in the record details, find which agency the possible result is coming from. Within EPStaffCheck specifically, this information can be found in column K of the QuickSearchResults.csv file for batch reports, or in the record details section on the very right of the screen for single searches. Once you find the sanctioning/excluding agency, try to locate the possible result within the original source to see if more information is given that could allow you to verify. Original sources for sanction/exclusion lists can be found in the Help section of EPStaffCheck.
• If no additional information is available after looking up the possible result on the original source, then you will want to determine which method of further verification mentioned below is required for the specific agency the result is coming from.

Verifying a Possible Match with Limited Information

Unfortunately, sometimes there isn’t much information other than a name given for a possible result. When this happens, further verification is required to make a determination. The ways to go about further verifying a possible match often depends on where the sanction/exclusion is coming from, as certain sanction/exclusion agencies have different methods of verification available. The good news is that while there are many different sanction/exclusion agencies, their verification processes usually fall into one of the following categories:

• Agencies like the OIG, New York OMIG, Texas OIG, Maine HHS, and Louisiana Medicaid have online verification tools you can use to verify a possible match within seconds if you have your searched party’s SSN available.
• Most agencies will have an email contact and/or a hotline where you can inquire about a possible match that is coming from their sanction/exclusion list. The email contact can usually be found on the same webpage that houses their sanction/exclusion list, though it can sometimes be on the list itself. You can also find contact information for specific agencies in the Help section of EPStaffCheck within the About the Databases folder.

Simplify Your Monthly Compliance Monitoring

If you have additional questions, please check out our other blogs in which we cover topics like What is a Compliance Program? and Why is OIG Compliance Monitoring Required? Additionally, if you would like to explore how Valenz and EPStaffCheck can help your compliance monitoring program visit our website for additional information.

We have covered the importance of OIG compliance monitoring in our previous blog post, but we have yet to really get into the “how” when it comes to checking the OIG Exclusion list, State Exclusion lists, SAM (System for Awards Management) EPLS, and the myriad other sanction/exclusion lists you may be inclined to check for compliance. The “how” is where Vālenz^® Health’s EPStaffCheck solution comes into play.

Your exclusion screening could just involve going to the OIG website and checking the individuals on your roster against the OIG list of Excluded Individuals, one by one, then repeating the process for state exclusion lists, then again for SAM EPLS, and so on and so forth each month. This consumes employee time that could be spent providing value elsewhere.

Exclusion Screening with EPStaffCheck

EPStaffCheck will let you upload your rosters and will check them against all those sanction/exclusion lists at the same time, and produce a detailed report for you in minutes. EPStaffCheck will immediately let you know which individuals are good to go, and which have possible results that warrant further investigation to ensure your organization isn’t in danger of being hit with a CMP from the OIG or another agency.

EPStaffCheck is also built to tailor directly to your needs as an organization. If you organization is small enough to where checking individuals one by one is your method of choice, you can still save time by checking individuals against multiple sanction/exclusion databases in one place. Need the ability to check batches of individuals and vendors all at one time? Then our Professional tier offers everything you need to ensure your compliance monitoring is top notch. For larger organizations, our Enterprise tier offers expedited support and an admin portal to manage users and set permissions. Beyond that, our Enhanced tier handles the bulk of your compliance monitoring for you, giving your organization one less thing to worry about each month.

On top of saving you time and helping you avoid costly mistakes on the exclusion side of compliance, EPStaffCheck also offers the ability to check licenses to ensure they are valid and up to date.

EPStaffCheck follows Office of Inspector General (OIG) best practices to ensure your organization is audit ready when the time comes with documentation trails to meet all JCAHO requirements.

Improve Your Compliance Monitoring Today

If you are interested in taking steps towards a rock solid compliance monitoring program, explore the tiers of EPStaffCheck or begin your free trial today.

Why is compliance monitoring required? This is a question that has likely crossed the mind of anyone working in compliance, but it’s also one that’s likely not pondered in much detail. Afterall, the “why?” is pretty easy to figure out, because the Office of the Inspector General (OIG) gives healthcare organizations guidelines for compliance monitoring. So rather than looking at the “why?” for compliance monitoring, let us instead look at “what if?”. What happens if compliance monitoring runs behind and someone slips through the cracks and your organization ends up hiring someone that is on the OIG Exclusion list?

So far in 2023, 17 different healthcare organizations have agreed to pay a total of $2.3 million dollars in settlements to the Office of the Inspector General (OIG) for employing individuals that have been excluded from participating in any Federal health care programs. Out of those 17 healthcare organizations, 8 were hit with settlements above $100,000 by the Office of the Inspector General (OIG) just for employing excluded individuals, and in January 2023, Dignity Health Medical Group settled with the OIG for $338,000, all for employing excluded individuals. In addition to those numbers, the settlements paid to the Office of the Inspector General (OIG) do not take into account whether those individuals were excluded by other federal or state agencies, which can often be the case and would carry their own separate penalties as well.

OIG Compliance Monitoring with Vālenz^® Health

At Vālenz^® Health, we’re committed to a strong, vigorous, and healthy vision of healthcare, and OIG compliance monitoring is an important part of that vision. Our product, EPStaffCheck, can help ensure your compliance monitoring program remains top notch by allowing you to monitor sanction and exclusion lists like the OIG Exclusion List, SAM, and all of the available state Medicaid databases all at once. EPStaffCheck will allow you to monitor your providers, staff, and vendors against sanction and exclusion lists to catch any possible compliance issues to ensure your organization does not end up on the wrong side of a settlement with the Office of the Inspector General (OIG).