Exclusion List Screening

The Office of Inspector General (OIG) is the Federal office, falling under the Department of Health and Human Services, tasked with identifying and eliminating Fraud, Waste, and Abuse (FWA). Most of us are familiar with the concept of Fraud Waste and Abuse and have taken the training numerous times that in the past was required. If we are responsible for credentialing our pharmacies we have attested to that training requirement.

In order to carry out their mission, OIG is also given the authority to "exclude from participation in Medicare, Medicaid, and other Federal health programs persons that have engaged in fraud or abuse and to impose Civil Monetary Penalties (CMPs) for certain misconduct related to Federal health care programs."

Exclusion means that the individual cannot bill Medicare, Medicaid, or any other Federal program....

1) For their services, or

2) At the medical direction or upon a prescription of an excluded person.

For #1, that includes:

  • Pharmacy technicians (who cannot assist in the filling of prescriptions)

  • Pharmacists (who cannot fill the prescriptions)

  • Cashiers that might ring the customers up

  • Providers that write prescriptions ultimately filled at the pharmacy.

If the individual is excluded and participates in any way in providing the services billed for, OIG has the right to recover all money paid out as well as tack on punitive fines.

These fines (termed "Civil Monetary Penalties," or CMP) for violating the regulations are steep. Just take a look at this case, cited directly from the OIG website (available here):

"06-20-2017 Florida Pharmacy Settles Case Involving Excluded IndividualOn June 20, 2017, Linton Square Pharmacy & Medical Supplies, Inc. (Linton Square), Delray Beach, Florida, entered into a $339,956.05 settlement agreement with OIG. The settlement agreement resolves allegations that Linton Square employed an individual who was excluded from participating in any Federal health care programs. OIG's investigation revealed that the excluded individual, a pharmacist, provided items or services to Linton Square patients that were billed to Federal health care programs. Senior Counsel Keshia Thompson represented OIG with the assistance of Paralegal Specialist Jennifer Hilton."

What if we didn't know the provider is excluded? Do we have to check all the providers in our database against an exclusion list?

Unfortunately, the answer could be yes; thankfully, there is help out there for that. This article from Computer Talk (a cool magazine, by the way, for all things tech in the world of pharmacy) discusses pre- and post-edits (PPE) in-depth and interviews a representative for a company that provides PPE solutions.

In it, she reinforces the financial penalties for pharmacies that dispense medications from a provider that is either not licensed or on the exclusions list, but states that their PPE will screen for those exclusions automatically as it hits the pharmacy switch and send the claim back with an error message if the provider is excluded.

Because it is impractical to screen providers for exclusion (and for plenty of other reasons), I highly recommend you invest in a PPE service if you don't already have one. If you are currently enrolled in one, it is probably worth giving them a call to be sure they offer the same level of provider screening.

About the databases

The OIG Database (LEIE)

OIG maintains the List of Excluded Individuals and Entities (LEIE) and updates the list monthly. For this reason, best-practice is to check the database not only at hire but also monthly afterwards. It is very likely that it is even a law in your state, considering CMS pushed state Medicaid directors 10 years ago to require monthly exclusion checks.

Also, most insurance companies require as part of their credentialing process that the pharmacy attest to checking all staff members within 90 days of hire and monthly afterwards. Because of the need to attest to doing so, the best thing to do is to have it documented (see below). From my experience re-credentialing pharmacies this attestation is on virtually every application.

State Exclusions Databases

In addition to OIG, state Medicaid programs also maintain their own exclusions list. The majority of states currently have them and, while they are required to coordinate with OIG to communicate changes and prevent billing of excluded individuals, they often don't have adequate procedures in place to do so. Take a look, for example, at this case where OIG found that Florida Medicaid had paid out $180,416 for services from excluded individuals - and that's just what they were able to find.

OIG and state lists won't match, partially because of inadequate communication between them, so it is best to check both databases once monthly.

Where can I find my state database? This article did the work for you and compiled a directory of all state databases as well as provide some additional information.

SAM Database

The System for Awards Management (SAM) is used for the Federal procurement (i.e. bidding to do business with the government). If an individual is debarred on the SAM database they are no longer allowed to bid on government contracts.

The OIG issued guidance after receiving inquiries about whether or not both databases needed to be checked by providers for their employees and/or contractors. OIG recommended using LEIE because:

  • LEIE is maintained and updated monthly by OIG (the enforcing authority for fraud and abuse)

  • OIG can assist with results on the LEIE and does not have access to SAM