According to the Occupational Employment Statistics from the Bureau of Labor Statistics, there are more than 16 million people working in the healthcare industry in the United States, making it one of the largest employment sectors in the country. The work that healthcare professionals perform is critical to American society, yet it is important for organizations that employ them to perform their due diligence to ensure each of their healthcare workers are properly licensed, have a clean history with their licensing board, and are not excluded from any state or federal programs.
Thoroughly screening prospective hires, current employees, and contracted businesses for any healthcare sanctions or exclusions is a crucial step employers need to take to guard their reputations and keep patients safe. Failure to do so can subject these organizations to penalties from the U.S. Department of Health and Human Services (HHS). The differences among terms like exclusion, sanction, and termination are important nuances CRAs need to identify in order to help healthcare organizations keep their employee rosters clean of fraud, revoked licenses, or state or federal program exclusion.
The OIG and License Revocation
The Office of the Inspector General (OIG), an HHS agency, is responsible for preventing and detecting fraud, waste, and abuse in Social Security Administration programs. CRAs can utilize the exclusion database provided by the OIG to search for those who may have had disciplinary actions issued in the past and are no longer eligible for SSA programs.
The OIG excludes from participation in all federal healthcare programs any individuals or entities who are convicted of committing Medicare or Medicaid fraud, along with various other offenses related to the delivery of items or services under Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), or other state healthcare programs.
However, just because an individual has been excluded from participation in federal healthcare programs does not mean that individual can no longer practice privately – potentially putting patients at risk and exposing employers to possible OIG exclusions or terminations.
It is a common assumption that most providers on the OIG List of Excluded Individuals/Entities (LEIE) arrived there by defrauding the Medicare or Medicaid systems. However, program-related crimes are the second-most common reason for exclusion. The most common reason why providers are excluded is due to license revocation or suspension.
Figuring out why a given provider’s license was revoked or suspended is not always easy. Often, the notes or minutes coming from the state licensing board do not specify a reason, as the relinquishment may have been voluntary. Additional digging is often required to get the full picture.
When a healthcare professional’s license is revoked (the most common kind of exclusion by the OIG), it occurs on the state level. At this point, according to the Centers for Medicare and Medicaid Services, any provider who is excluded in one state should be excluded in all states. There is no national database that tracks license revocations, so in some cases, even individuals who have had their licenses revoked in one state move elsewhere and continue to practice. This can have significant negative effects for both employers of healthcare providers – damaging a healthcare employer’s reputation and exposing them to further sanction from the OIG.
What happens when a healthcare professional falls through the cracks of the system?
A case like this occurred in 2019, providing a clear warning to employers in the healthcare industry. Laura Lynn Bell was a nurse in Arizona when her license was suspended in 2015 for domestic violence arrest, among other charges. From there she went on to defraud the Department of Veterans Affairs of almost $800,000. Without a license and with charges against her, Bell attempted to steal an identity, forging documents and papers in the name of Alicia Houston. This was a skill she honed while working for Veteran Affairs, when she stole the identities of nurse practitioners and former patients to bill for medical services.
According to Nursys, a site created to report nursing disciplinary action on a state level, Bell was able to practice nursing in six different states and had an application in process with a seventh before she was caught and her licenses revoked.
People like Laura Lynn Bell must be carefully scrutinized because they do what they can to stay under the radar and emerge somewhere else, where they can continue to harm the people they look after. This makes it essential to check against databases such as the Federal OIG since these databases allow checks by Social Security number. Undoubtedly there will be those who find a way to change their SSNs, but the extra precaution might unearth clues to things behind the scenes.
Many similar cases exist, and it is up to departments like the OIG to discover, report, and exclude individuals who are working the system to their advantage. Organizations that have hired and continue to employ individuals excluded by the OIG can receive significant civil monetary penalties (CMP) for doing so. This kind of enforcement helps ensure those who are not permitted to provide state and federally funded healthcare are kept from providing healthcare services in federal healthcare programs.
In addition to routinely checking their enrollment roster against the LEIE maintained by the OIG, the System Awards Management (SAM) list, and the state Medicaid exclusions lists along with screening all incoming employees for these exclusions, employers should also watch employee licensure regularly and monitor all licenses an employee may have in other states.
These healthcare organizations should ensure they have adopted a process to mitigate compliance risk, utilizing technology and comprehensive information derived from checking the primary source data and gathering the information they need to prevent hiring and employing excluded individuals.
In addition to tracking updates to regulatory requirements and exclusion lists, healthcare organizations should have a process in place to mitigate compliance risk and ensure quality of care. The right technology and comprehensive information derived from checking the primary source data can provide employers the key information they need to help prevent hiring, employing, and doing business with a sanctioned or excluded individual or entity.
It can be challenging for healthcare organizations to stay up to date in compliance requirements. Appriss Insights will be hosting a webinar that will discuss cutting-edge ways CRAs can gather crucial risk-related information to ensure quality care, protect institutional reputation, and maintain compliance. The webinar exploring ProviderSafe, Appriss Insights' comprehensive set of wholesale compliance and credentialing solutions powered by Typhoon Data, will be on Tuesday, November 17, from 2:00 to 2:45 p.m. EST.