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Tips On Physician Sanction Screening

Sanction screening physicians and other medical staff is not optional.  Failing to sanction screen may result in a violation of the conditions of participation in Medicare/Medicaid, and could lead to financial penalties or other actions by the Office of Inspector General (OIG).  The Centers for Medicare & Medicaid Services (CMS) and many state Medicaid agencies are now calling for monthly sanction screening.  These demands create an ongoing burden for an organization in terms of time, effort and cost.  Due to this burden, some organizations have gone beyond the requirements, engaging in unnecessary screening and resulting in added complications and problems.  One of the most common examples of unnecessary screening involves physicians who are not employed and do not have staff privileges.  Every hospital receives periodic referrals from physicians with whom they have no established relationship.  For example, it is common for doctors to refer retired “snow birds” while they are spending time in warmer weather for services when they return to their home area.  This also frequently occurs where a state line is nearby and someone is referred from one state to another for a service.  It is important to note that neither CMS nor the OIG call for such screenings.  Although it is good to try to do the “right thing” by screening everyone, this practice comes at a cost.  The following points on the subject are worth consideration:

  • Over time, hundreds of referrals may be made by physicians with whom the hospital has no personal contact. Screening these physicians results in time and cost consumption, especially where resolution of potential hits is necessary.
  • Physicians who refer a patient to a hospital: (a) may not be from the area; (b) may not have been to the hospital or have previously referred a patient to the hospital; and (c) may never refer another patient to the hospital again. Little is known about the physician and the relationship between the hospital and physician is minimal.
  • The absence of physician identifiable data in these circumstances makes it difficult to permit a positive determination of whether a potential “hit” is linked to someone listed on the List of Excluded Individuals and Entities (LEIE).
  • In most cases, it is not possible for a hospital receiving a patient as a referral from an unknown physician to conduct the screening and resolution process before the provision of services.
  • If it is found that a physician who has referred a patient is identifiable to someone on the LEIE, health care organizations often do not know how best to proceed. First, any services rendered to the patient as result of the referral should not be charged to Medicare/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.

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Additional Tips And Suggestions

  1. Hospitals 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, hospitals should give serious consideration to avoiding unnecessary screening.
  2. If unaffiliated physicians make frequent referrals, it is best to screen them. In all likelihood, these physicians will be identifiable in some way by the hospital.  It is advisable to report any confirmed “hits” by these physicians to the OIG.
  3. Before contacting any unaffiliated physician to inform them that they have been found on the LEIE, hospitals should take special care in confirming that they are indeed identifiable with the excluded party. Nothing is worse than falsely accusing a physician of being excluded from participation in Medicare/Medicaid due to a mistake in identity. The use of UPIN/NPI data provides information about physicians including their specialty and practice areas.  Using this data is relatively easy and can be an effective method to accomplish accurate screening in the absence of identifying data.
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