Ongoing Monitoring of Your Providers and Staff - Compliance Made Easy

In Spring of 2018, the Health and Human Services Office (HHS) released their findings with regards to savings recognized through the work of the Office of the Inspector General (OIG). In the report the HHS states “OIG remains at the forefront of the Nation’s efforts to fight fraud in HHS programs and hold wrongdoers accountable for their actions. Not only does fraud increase HHS costs, it increases risk and potential harm to beneficiaries”.

The report noted that in 2018:

• Expected investigative recoveries of $1.46 billion
• Criminal actions against 424 individuals or entities that engaged in crimes against HHS programs
• Exclusion of 1,588 individuals and entities from Federal health care programs
• Civil actions against 349 individuals or entities

How can your organization prevent excluded individuals in federal health care programs from joining your organization?

Monitoring for Sanctions

Ongoing sanctions monitoring is the process of reviewing information on a periodic basis to ensure compliance, exclusions and sanctions have not occurred with regard to your provider. Providers sanctioned in one state can quickly move and open an office in another, affecting network quality and member service. Healthcare organizations that comply with federal and state provider network requirements can avoid costly penalties. To meet this compliance requirement, most organizations are performing monitoring for physicians, referring physicians, independent and dependent health providers and nursing staff.

As we all know, manual monitoring activities can be prone to error and very time consuming. Calling, faxing or emailing many different organizations to receive a response is inefficient and unsustainable. The industry has seen tremendous growth in numbers of organizations who have moved verification and monitoring information to electronic data sources accessed via the internet to eliminate phone calls, faxes and paper. Why not access these sites electronically, automatically query each site for the desired information and have the results returned to you almost immediately?

Sanction sites to be monitored include OIG, System for Award Management (SAM), FDA, DEA, FBI’s Most Wanted List, Social Security Death Master File, state licensing boards, CMS Open Payments and more. Automatic queries to these sites can be done on a predetermined basis. Queries can be configured on scheduled intervals to run monthly, quarterly, etc. depending upon how frequently the sites update their data sources.

The results are usually returned within minutes of the requests and all historical data is maintained. Some systems include a dashboard of information to enable staff and managers to quickly see completed queries for monitoring of volume records. In addition to ensuring regulatory compliance, this automated process provides a hands-free solution to this labor intensive task saving time, money and reducing those manual processing errors.

Who Should Consider Using An Automated Sanctions Monitoring Solution?

Any medical staff office or credentialing verification organization who is credentialing healthcare providers, human resource departments, compliance offices, enrollment and medical practices; All of these entities should be performing sanctions monitoring and consider an automated solution to ensure the most up to date information is on hand.

Before hiring new individuals or vendors, all potential employees should be screened against all available federal and state exclusion and sanctions lists. This screening process should apply to temporary individual providers and vendors as well.

Not only should you screen all new employees and vendors, but consider implementing a monthly monitoring process to check both new and existing employees and vendors on all available federal and state lists. This will ensure your organization is better equipped to address OIG compliance requirements.