Compliance Tool: Model Mandatory Excluded Provider Screening Policy

Hiring, contracting, retaining, or continuing to do Medicare-related business with excluded individuals or entities can put your lab at risk of civil monetary penalties of up to $13,508 per item or service billed, treble damages, liability under the False Claims Act, criminal penalties, and even the ultimate penalty: exclusion from federal and state health programs. The first line of defense is to perform checks to ensure that your current and prospective employees and contractors aren’t on the U.S. Department of Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals/Entities or other federal and state excluded persons lists. Checks should be performed both prior to initial engagement or hiring and on a continuous basis each month. In addition, you should implement a written policy establishing your right to do excluded persons checks and take appropriate actions if they come back positive. Here’s a basic Model Policy that you can adapt for your own circumstances.

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Exclusion Screening Policy

1. POLICY

Federal law provides that no federal healthcare program payment may be made for any items or services (1), furnished by an excluded individual or entity, or (2), directed or prescribed by an excluded physician. Billing Medicare or other federal health programs for any items or services furnished by an excluded individual or entity may result in the imposition of civil monetary penalties (CMPs) and other fines and penalties, including potential exclusion. ABC Laboratories will take all necessary measures to ensure compliance with these requirements.

2. PURPOSE

The purpose of this Policy is to ensure that all ABC Laboratories employees, medical staff, contractors, subcontractors, and other business associates are properly screened to verify that they have not been excluded and are authorized to participate in federal and state health programs.

3. BAN ON ENGAGING EXCLUDED PERSONS

ABC Laboratories will not hire, employ, contract with, or enter into a business relationship with any individual or entity who:

• Is currently under sanction or exclusion by the Department of Health and Human Services Office of Inspector General (OIG) or any other duly authorized enforcement agency or licensing and disciplining authority
• Has been recently convicted of a criminal offense related to healthcare
• Is listed as excluded or otherwise ineligible for participation in federal healthcare programs

4. BAN ON RETAINING EXCLUDED PERSONS

ABC Laboratories shall remove individuals with direct responsibility for or involvement in any federal health program, as well as those facing felony or serious misdemeanor criminal charges or proposed exclusion sanction. Current contractors and subcontractors of ABC Laboratories who are facing such criminal charges shall be suspended from continued work until the matter is satisfactorily resolved under the criminal justice system.

5. MANDATORY SCREENING

ABC Laboratories will not hire, contract with, or enter into a business relationship with any individuals, medical professionals, or entities involved in the provision of items or services reimbursable by federal health programs unless and until competent ABC Laboratories personnel screen them against:

• The OIG List of Excluded Individuals/Entities (LEIE)
• The Center for Medicare and Medicaid Services (CMS) Medicare Preclusion List
• The State of ___ Medicaid Exclusion List
• The General Services Administration’s SAM.gov (System for Award Management database)

ABC Laboratories shall immediately terminate any individual or entity that it determines to be listed as excluded in any of the above sources.

6. EMPLOYMENT CONTRACT PROTECTIONS

The following language must appear in all ABC Laboratories employment contracts with physicians:

6.1 Mandatory Language for “Physician Representations and Warranties” Section of Contract

(a) Physician has disclosed and will immediately disclose to ABC Laboratories all of the following matters, whether they occur before or during the contract term:

• Any legal actions, suits, or proceedings pending or threatened against Physician and directly or indirectly affecting ABC Laboratories, including but not limited to, all medical malpractice suits
• Any criminal complaint, indictment, or criminal proceedings in which Physician is named as a defendant
• Any investigation or proceeding, whether administrative, civil, or criminal, relating to an allegation against Physician for filing false healthcare claims, violating anti-kickback or self-referral laws, or engaging in billing improprieties
• Any physical or mental illness or condition that impairs or may impair Physician’s ability to practice medicine
• Any dependency on, or habitual use or episodic abuse of, alcohol or controlled substances, or any participation in any alcohol or controlled substance detoxification, treatment, recovery, rehabilitation, counseling, screening, or monitoring program
• Any allegation or investigation or proceeding based on any allegation against Physician of violating professional ethics or standards of care or engaging in illegal, immoral, or other misconduct (of any nature or degree), relating to the practice of medicine
• Any denial or withdrawal of an application for (i), licensure as a physician in any state, (ii), medical staff privileges or membership at any hospital or other healthcare entity, (iii), board certification or recertification, (iv), participation in any payment program, (v), state or federal controlled substances registration, or (vi), professional liability insurance.

6.2 Mandatory Language for “Contract Term and Termination” Section

Physician has an affirmative obligation as a condition of continued employment to report to ABC Laboratories any investigation or inquiry by any hospital or other healthcare institution, managed care organization, regulatory agency, governmental authority, or professional society regarding any item or activity against or affecting Physician, whether material or not.

7. MANDATORY CONTRACT LANGUAGE CERTIFYING ACCURACY OF INFORMATION

All ABC Laboratories employment applications and contracts must include a statement indicating that accuracy of all information provided is a condition of employment or contract, and that furnishing any incorrect, incomplete, inaccurate, or misleading information is grounds for immediate termination of said employment or contract. Applications and contracts must also include a statement that grants the right to verify all information provided in any employment application or contract agreement.

8. VERIFICATION OF IDENTITY

To ensure fairness and avoid cases of mistaken identity, ABC Laboratories will exercise due diligence to verify that any party found on an exclusion list is the same individual or entity being considered for or currently holding employment, a contract, or other business relationship with ABC Laboratories.

9. MANDATORY MONTHLY SCREENING

In addition to the screening provided for under Section 5 above, ABC Laboratories will perform excluded person screening of applicable individuals and entities in the same manner but also on a monthly basis. ABC Laboratories shall immediately terminate any individual or entity that it determines to be listed as excluded in any of the sources included in Section 5.