The ABC’s and FAQ’s of Exclusion Monitoring Not so easy as 1,2,3… ProviderTrust, Inc. All rights Reserved. Copyrighted

Hello and Welcome! ProviderTrust, Inc. All rights Reserved. Copyrighted David Servodidio Associate, ProviderTrust x 7017 Reed Thompson Associate, ProviderTrust x 7014

The Law OIG has authority to exclude individuals and entities from federally funded health care programs under Sections 1128 and 1156 of the Social Security Act. PPACA Excluded in One, Excluded in All CMS Guidelines- recommends, with guidance, monthly monitoring for exclusions (March 2011) State Medicaid Director Letter June 2009 Directing states to remind providers (Employers) obligation to monitor State Medicaid Bulletins to Providers- 17 States Some states extend exclusions to referring or ordering physicians NY requires searching for exclusions in adjacent states

What and Why of Exclusions Definition- Administrative action (based on criminal convictions and/or license revocation) Length (from 5 years to indefinite) Reinstatement (must apply for, not always granted). Self Disclosure- If you discover your organization has employed, contracted with or billed CMS. (Will help reduce fines) Civil Monetary Fines/Penalties –$10,000 per item claimed –Treble Damages

Two Types Mandatory- OIG required to exclude: –Medicare/Medicaid fraud- including CHIPS, Tricare –Patient Abuse or neglect –Felony convictions for fraud, theft or other financial misconduct –Felony convictions for unlawful manufacture, distribution, prescription or dispensing controlled substance Permissive- OIG has discretion to exclude: –Misdemeanor convictions related to health care fraud –Fraud in a program (other than a health care program) –Misdemeanor convictions for unlawful manufacture, distribution, prescription or dispensing controlled substance –Suspension, revocation or surrender of license to provide health care due to competence –Submitting of false/fraud claims to federal health care program –Defaulting on federal student loan or scholarship obligations –Controlling a sanctioned entity as an owner, officer or managing employee

Who and What can be Excluded? Applies to all employees (licensed or not), contractors, vendors and referring physicians Several State Medicaid Bulletins require monthly monitoring Submitting reimbursement for Excluded Persons or Entities can result in a False Claim Act violation –in whole in part, directly or indirectly, for items, services or expenses claimed or submitted for reimbursement Corporate Integrity Agreements implemented for violators of Fraud and Abuse claims- include monitoring requirement –Extend requirements to pending charges and/or actions that could result in exclusion, if convicted –Note: Default on federal student loan can result in an exclusion

CMS’ View of Exclusions PPACA required CMS Guidance Final Guidance effective March 2011 Recommend with Guidance to conduct monthly

OIG: The Ultimate Excluder Inspector General Levinson: “We update monthly, so we recommend you search monthly”. More guidance expected. Work Plan Section IV Statutory Authority CMP Enforcement Complier of LEIE Mandatory vs. Permissive CIA’s for non-compliance –Added requirements for Exclusions

Reinstatements After term of Exclusion (usually 5 years) individual or entity can apply for reinstatement Administrative process Not automatic Must apply at both state and federal OIG and SAM

OIG-LEIE vs. GSA/EPLS What’s SAM got to do with it? GSA administers EPLS and SAM, both of which contain debarment actions taken by various federal agencies, including exclusion actions taken by the OIG. The OIG List of Excluded Individuals/Entities contains just the exclusion actions taken by the OIG. SAM should be included along with OIG- LEIE ProviderTrust, Inc. All rights Reserved. Copyrighted

OIG-LEIE Scope Created in the early 1990’s by HHS OIG OIG’s LEIE only covers individuals /entities where taken by the OIG Effects ability to claim payment or reimbursement by a federal healthcare program for items and services rendered Audit: OIG LEIE missing up to 61% State Medicaid Exclusions –Note: GSA and new SAM database contains Exclusions/Debarments and there are now 26 state Medicaid Exclusion lists. ProviderTrust, Inc. All rights Reserved. Copyrighted

| Summary of OIG Exclusions by Type ProviderTrust, Inc. All rights Reserved. Copyrighted

Most common Exclusion: License Revocation, Suspension

| 14 Civil and Criminal Actions: NOTE: Average fine from OIG exceeds $100,000 per individual ProviderTrust, Inc. All rights Reserved. Copyrighted

Why SAM? PPACA funded and Congress tasked Government agencies to work together and build or integrate databases Includes more than just Debarred, Excluded or Sanctioned individuals and entities –DOD, EPA, CCR, FAR, and other government contracting exclusions ProviderTrust, Inc. All rights Reserved. Copyrighted

Nuances within SAM Address- which one? DUNS or CAGE # (not SSN)- for Vendors Case Sensitive (ie. P.O. Box vs P O Box) Manual Verification with Agency required to match.- phone call Disclaimer: when possible matches are identified, there may be instances where an individual or firm has the same or similar name but is different party. (SAM does not have DUNS on all companies. ProviderTrust, Inc. All rights Reserved. Copyrighted

| 17 Exclusion Sources OIG-LEIE (List of Excluded Individuals & Entities) GSA/SAM- Excluded Party List System and System for Award Management 26 state Medicaid Exclusion Lists (+ D.C.) Alabama, Arkansas, Arizona, Connecticut, District of Columbia, Florida, Hawaii, Idaho, Illinois, Kentucky, Maryland, Maine, Michigan, Mississippi, Nebraska, New Jersey, Nevada, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Washington, West Virginia, and Wyoming ProviderTrust, Inc. All rights Reserved. Copyrighted

| 18 Questions? Thanks for Joining! ProviderTrust, Inc. All rights Reserved. Copyrighted David Servodidio Associate, ProviderTrust x 7017 Reed Thompson Associate, ProviderTrust x 7014