Health Care Sanction Checking and Monitoring is Critical — Best Practices to Follow

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According to a recent Health Care Fraud and Abuse Control Program (HCFAC) report, fraud is on the rise. A February 2012 U.S. Department of Health & Human Services (HHS) press release revealed that the Health Care Fraud Prevention & Enforcement Action Team (HEAT) helped the Department of Justice and HHS recover $4.1 billion in taxpayer dollars in 2011. At the time of the press release’s publication, this was the highest amount recovered from companies and individuals involved in fraudulent activities.

Assembled in 2009, HEAT’s purpose is to prevent waste, abuse and fraud within the Medicaid and Medicare programs, as well as crackdown on those abusing the system. With the help of tools and resources provided by the Affordable Care Act, the efforts of HEAT and the HCFAC will only continue to intensify. As proof of this good work, the HHS Office of Inspector General (OIG) issued a November 2012 press release reporting that it expects to recover about $6.9 million from investigations and audits in 2012. Furthermore, the OIG excluded 3,131 entities and individuals from participation in federal health care programs for violations such as intentionally hiring individuals with medical sanctions, a Civil Monetary Penalties (CMP) violation.

About Medical Sanctions

OIG guidelines clearly state that health care organizations cannot employ sanctioned or excluded individuals. Such individuals are listed on the U.S. General Services Administration (GSA) System for Award Management (SAM) (includes Excluded Parties List System (EPLS)) and the OIG List of Excluded Individuals (LEIE) for incidents such as patient abuse, fraud, professional violations or reprimands, and other types of professional misconduct. The risks involved with hiring an individual or vendor who is sanctioned or excluded can include fines, OIG audits, jail time, suspension from federal health care program participation and a damaged reputation.

Health Care Sanction and Monitoring Best Practices

With the potentially dire consequences that come with non-compliance and hiring an excluded or sanctioned individual, it is in a health care organization’s best interest to evaluate its employee screening program regularly and consider the following best practices:

  • Be familiar with the latest federal and state requirements – The OIG continually makes changes to its guidance and requirements. For example, on May 8, 2013 the OIG issued an Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs recommending monthly health care sanction checks. Incidentally, a health care organization’s respective state may have its own professional monitoring requirements and a list of state-level exclusions or sanctions that must be checked.
  • Run checks on existing employees and contingent workers – Re-checking employees will help you identify actions taken against them since you last screened them. But non-employees or contingent workers such as third-party vendors, volunteers, temporary workers and consultants can pose the same level of risk. Re-checking employees and screening contingent workers allows a health care company to address potential gaps in its current monitoring procedures.
  • Tighten pre-employment and pre-contract background checking policies – Before hiring anyone or contracting with a new contingent worker, an organization should have a comprehensive background screening process that looks for sanctions and exclusions.
  • Monitor current employees and contingent workers: An initial background screen isn’t enough because the SAM and LEIE lists are regularly updated. If an organization’s state doesn’t already require regular monitoring, a health care company should consider implementing a monthly or quarterly exclusion- and sanction-checking policy of its own.
  • Use automated monitoring tools – Health care organizations may easily employ and contract hundreds of individuals, which can make ongoing manual sanction and exclusion monitoring difficult. Automated monitoring tools can automatically add individuals from a pre-hire and pre-contract screening program to the system. If a scheduled monitoring reveals an excluded or sanctioned individual or vendor, the system will notify the health care company. Reputable employee screening providers can help an organization set up an automated monitoring system.

It’s never too late for an organization to take additional steps to protect its patients, employees and reputation. For more information on sanction and exclusion monitoring best practices, download HireRight’s free whitepaper “Identify Your Riskiest Health Care Employees“ here



HireRight is a leading provider of on-demand employment background checks, drug and health screening, and electronic Form I-9 and E-Verify solutions that help employers automate, manage and control background screening and related programs.

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