Searching State Exclusion Lists: Why It Matters for Assured Compliance

If your profession involves compliance management, you know the Office of Inspector General’s List of Excluded Individuals/Entities (OIG LEIE) is the federal database for all Medicaid sanctions – and no doubt your team checks it regularly for sanctioned providers. However, many investigations are conducted by state Medicaid offices and do not always include federal participation. Is your compliance team checking for sanctions and exclusions at the state level as well? If not, they should be.

In fact, OIG Best Practices state that you should also search every state sanction and exclusion list that corresponds with your business or service delivery location(s) – meaning, all states where you operate or have a physical business presence. Some organizations are required to check all 41 state Medicaid sanction lists, but if yours is not one of them, our compliance experts recommend at least checking border states and any other state where the providers in your network or health system have practiced in the past.

Why? Because state actions may appear before federal listings, and in some cases, the states and federal databases do not fully synchronize their entries. But, to be clear, if a person or organization you do business with is excluded by your state, you will face the full threat of repercussions, for hiring and reimbursing them, even if they do not appear on the federal exclusion list.

What do those repercussions look like? In addition to the loss of your reimbursement funds plus interest, civil monetary penalties may apply – not to mention reputational damage and potential legal liability. When it comes to non-compliance, the risks and penalties can be great, so the time and costs associated with checking every applicable sanctions and exclusion list, including state lists, is well worth it.

Also worth noting: To screen thoroughly, you must search lists from state licensing and medical boards, as well as state and county disciplinary action lists and abuse registries (including state/local consumer affairs, addiction recovery lists and more). Checking all lists, not just the major ones, helps ensure compliance by alerting you to providers who may have had fines imposed or faced certain allegations but have not formally been sanctioned.

If you don’t have the internal manpower to ensure no stone is left unturned, good news: Affordable outsourcing options are available. At Vālenz Assurance, we offer a range of compliance software and support solutions to meet your needs and budget. To learn more about how we take the complexity out of compliance, call 888-395-9029.

Building an Effective Compliance Management Program: What You Need to Know

To help prevent fraud and abuse – and all the punitive setbacks that come with broken health care laws and unmet regulations – having a robust compliance program is key. There is no one-size-fits-all approach to compliance management, however, and it is most effective to tailor your program to your organization’s structure and type. The following FAQs are designed to help you understand the basics and formulate next steps for your compliance program.

What is a compliance program, and why do I need one?

A compliance program is a set of internal policies and procedures that helps your organization comply with the law in its daily operations. A proactive plan helps you maintain compliance with today’s regulations, as well as providing a framework for implementing future requirements.

What are the basic components every compliance program should include?

Effective compliance programs include these essential components:

  • Written policies and procedures
  • Effective training and communication
  • Internal monitoring and auditing
  • Enforcement and discipline
  • Prompt action/response times for issues detected

Why should I customize my organization’s compliance program?

Every organization is structured differently, has unique staffing and contracting programs, provides a different mix of services, and has a specific profile of patient demographics and payer mix. While the basic essentials apply to any compliance program, the specifics will vary based on your organization’s unique operations, structure, and areas of risk.

What resources are available to help me customize my compliance program?

To help you develop a compliance program that is most impactful for your organization, the Office of Inspector General (OIG) has developed a set of principles, called Compliance Program Guidance (CPG). These guidance documents are geared toward different segments of the healthcare industry, including:

  • Hospitals, Nursing Facilities, Physician Practices, Home Health Agencies, Hospices
  • Medicare+Choice Organizations
  • Third-Party Medical Billing Companies
  • Public Health Services (grants)
  • Pharmaceutical Manufacturers
  • Clinical Laboratories
  • Ambulance Suppliers
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supply Industry

Use the CPGs as a starting point, and then tailor them for your organization. The OIG provides many additional compliance resources to encourage effective internal controls to monitor and manage adherence to applicable statutes, regulations, and program requirements.

Also, remember that a compliance program is never done – it evolves with your business and with changing regulations. It is forward-looking, and focused not only on risk containment, but also on best care and management practices.

This sounds like more than my small team can manage. Can I outsource my compliance program instead?

Yes! At Vālenz™, we offer a range of compliance software and support solutions to help assure you are not the “last to know” about a sanctioned provider or other compliance issue. With three tiers of service to accommodate any need and every budget, we take the complexity out of compliance and deliver peace of mind. To learn how we help you protect your organization from the risks of non-compliance, call 888-395-9029.

Colin Glen Joins Senior Executive Team at Vālenz Assurance

Vālenz, a leading innovator for solutions that reduce medical claim costs and promote quality healthcare, has recently expanded its strategic acumen by welcoming Colin Glen to the executive team. Glen is now Vice President of Business for Vālenz Assurance, which delivers solutions for assured compliance and payment integrity as part of the firm’s comprehensive health administrative ecosystem.

Having held leadership positions at such firms as Intelligent Medical Solutions, Oration, WhiteCloud Analytics and, most recently, Relias, Glen brings nearly 20 years’ experience to his new role.

“Throughout his career, Colin has excelled at serving the needs of the health industry with technology and data-driven solutions,” said Rob Gelb, Chief Revenue Officer at Valenz. “He has an in-depth understanding of our clients’ needs and how to address them with our innovative and uniquely comprehensive platform. We are thrilled to have him on the Valenz team.”

Glen is well-positioned to support the Valenz growth strategy – and that growth, he says, is a key component to smarter, better, faster healthcare. “We ensure the integrity of data for clients who rely on our coding, compliance and credentialing solutions, as well as for the Valenz ecosystem,” Glen explained. “Ultimately, our solutions positively affect our clients’ capacity to reduce costs while improving care quality and outcomes.”

For more information about the complete health administrative ecosystem or any of its core components available through Valenz, call 877-762-4455.

About Valenz

Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Serving self-insured employers, third-party claim administrators, brokers and benefit consultants, trust and labor organizations, stop-loss carriers, integrated healthcare delivery networks, and health/dental plan payers, Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available online at valenzhealth.com. Valenz is backed by Great Point Partners. For more information about Valenz, visit www.valenzhealth.com or call (866) 762-4455.

About Great Point Partners

Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading health care investment firm, currently with approximately $1.8 billion of equity capital currently under management and 28 professionals, investing in the United States, Canada, and Western Europe. GPP is currently making new private equity investments from GPP III. Great Point manages capital in private (GPP I, $156 million and GPP II, $215 million of committed capital, and GPP III which has $306 million in committed capital) and public (BioMedical Value Fund family, approximately $1.1 billion) equity funds. Great Point Partners has provided growth equity, growth recapitalization, and management buyout financing to more than 100 growing health care companies. The private equity funds invest across all sectors of the health care industry with particular emphasis on biopharmaceutical services and supplies, outsourcing and alternate site care, pharmaceutical infrastructure and information technology enabled businesses. The firm pursues a proactive and proprietary approach to sourcing investments and tuck-in acquisitions for its portfolio companies. Reach Great Point at (203) 971-3300 or www.gppfunds.com.