The Former HHS Inspector General Offers Tips To Improve Your Physician Sanction Screening Process

Richard P. Kusserow | October 2015

Conducting sanction and exclusion checks on staff physicians is not optional. Failing to conduct sanction and exclusion checks can result in a violation of the federal healthcare program requirements, financial penalties and/or enforcement actions taken by the Department of Health and Human Services Office of Inspector General (OIG). The healthcare organization is increasing their risk by not conducting ongoing sanction and exclusion checks of their physicians.

The Centers for Medicare & Medicaid Services (CMS) and most state Medicaid agencies are calling for monthly sanction and exclusion screenings. Monthly screening creates a burden on the compliance staff in terms of time, effort and cost. Many healthcare organizations end up doing more than is required, which creates an even larger burden on their resources and creates complications and problems within the sanction and exclusion screening process. One of the most common mistakes of doing more than what is required is screening physicians that are not employees and do not have staff privileges. Every healthcare facility receives periodic referrals from physicians with whom they have no established relationship. For example, it is common for physicians to refer retired “snow birds” who are spending time in warmer weather to seek services when they return to home. Another example is when healthcare organizations are near the state boarder. Often times they receive referrals from physicians that are located in the neighboring state. CMS does not require healthcare organizations to screen referring physicians. Although it is good to do the “right thing” by screening everyone, this practice comes at a cost.  The following points on the subject are worth consideration.

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First, over time, hundreds of referrals may be made by physicians with whom the healthcare facility has no business or referral agreement and they remain in your system. Physicians who refer a patient to a facility: (a) may not be from the area; (b) may not have been to the facility or have previously referred a patient to the facility; or (c) may never refer another patient to the hospital again.  Many times these referring physicians have made only one referral to your facility, yet they stay in your system. Little is known about the physician and the relationship between the hospital and physician is minimal.

Second, the absence of physician identifiable data in these circumstances makes it difficult to permit a positive determination of whether a potential match is linked to someone listed on the OIG’s List of Excluded Individuals and Entities (LEIE), the General Services Administration’s System for Award Management debarment list (GSA SAM) or a state Medicaid exclusion list. Screening these referring physicians results in time and cost consumption, especially where resolution of potential matches to exclusion and sanction records is necessary.

Third, in most cases it is not possible for a facility, who is receiving a patient as a referral from an unknown physician, to conduct the screening and resolution process before the provision of services.

Fourth, if it is found that a physician who has referred a patient is identifiable to someone on the LEIE, GSA SAM or Medicaid exclusion list, the healthcare facility often does not know how best to proceed. Any services rendered to the patient as result of the referral should not be charged to Medicare or Medicaid regardless of medical necessity. The harder questions include whether to: (a) report the suspected physician to the OIG; (b) notify the physician in writing that they have been identified as being on the LEIE and to not refer patients in the future; and (c) notify the patient of the finding.  All of the answers to these questions may lead to additional and more complex problems. If a referring physician is found to be a confirmed match, it is advisable that you contact the physician. However, before contacting the unaffiliated physician, the healthcare organization should take special care in confirming that they indeed matched the referring physician to the right excluded party. Nothing is worse than falsely accusing a physician of being excluded from participation in federal healthcare programs due to a mistake in identity. The use of national provider identifier (NPI) data provides information about physicians including their specialty and practice areas. Using NPI data is relatively easy and can be an effective method to accomplish accurate screening in the absence of identifying data. You should report any confirmed matches of referring physicians to the OIG.

In conclusion, healthcare organizations are required to screen only those physicians with whom they have an established relationship. Since there is no requirement or obligation to screen physicians with whom there is no established relationship, healthcare organizations should give serious consideration to avoiding unnecessary screening.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.