OIG Imposes Record Penalties for Exclusion Violations

OIG Imposes Record $21.5 Million in Penalties for Exclusion Violations!

The OIG imposed a record $21.5 million civil money penalties and restitution against an Ohio corporation that operates pharmacies and supermarkets in 34 states for exclusion violations involving the employment of excluded individuals and fulfilling prescriptions by excluded prescribers! The settlement alleged that the company filled prescriptions from 84 excluded pharmacists and directly employed 14 pharmacists that had been excluded from federal health care programs.

The Office of Personnel Management participated in the investigation through its Office of Inspector General and confirmed that 14 direct employees had been debarred from participating in the Federal Employee Health Benefit Program (FEHBP). OPM received over $314,000 in penalties and $628,000 in restitution as part of the settlement.

Federal Health Care Programs do not pay for items or services that are provided, either directly or indirectly, by excluded individuals and the Office of Inspector General also has the authority to impose Civil Money Penalties on providers that knowingly submit such claims. Providers that fail to screen on a monthly basis to identify excluded employees or vendors are considered to have knowningly submitted such claims related to such persons or entities.

When the OIG announced last June that it had created a Special Litigation Unit dedicated to enhancing its enforcement of OIG Exclusion Requirements and Civil Money Penalty, it put the provider community on notice of its continuing commitment to enforce exclusion screening requirements and punish exclusion violations. Since that time, it has announced over 50 settlements involving the employment of exclusion individuals including a number of recent large settlements.

Are you taking the necessary precautions to ensure you are not working with an excluded entity? We know it can be difficult to screen every Federal and State exclusion list. Call Exclusion Screening at 1-800-294-0952 or fill out the form below to hear about our cost-effective solution and for a free quote and assessment of your needs.

Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime health care lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should you have any questions at: pweidenfeld@exclusionscreening.com or 1-800-294-0952.

DOJ Files Another False Claims Act Case Based on OIG Exclusion Violations

DOJ Pursuing Action on Two Separate OIG Exclusion Violations

The U.S. Attorney’s Office in Philadelphia filed a False Claims Act case last week based primarily on OIG exclusion violations. The c omplaint alleges that the defendant filed several documents concealing his exclusion and his role in Mental Health Clinics ostensibly run by his wife. Medicare and Medicaid do not pay for services provided, either directly or indirectly, by someone who is on the OIG List of Excluded Individuals (LEIE) or on a State Medicaid Exclusion List. The lawsuit comes on the heels of a suit with similar allegations brought by that office in May. It further evidences the increasing interest of OIG and DOJ in enforcing exclusion regulations and exclusion screening requirements.

The filing was announced by United States Attorney Zane David Memeger. He stated that, “this civil complaint reflects our focus on pursuing individuals who defraud Medicaid and Medicare, especially after they have previously defrauded those programs and been barred from participating in them.” The complaint also alleges fraudulent billing for services provided without proper supervision and by unqualified persons.

While both cases involve similar fact patterns (persons concealing their exclusion status and involvement in a company) and were filed within months of each other, it is significant to note that they arose in completely different ways. The most recent case’s complaint is a whistleblower lawsuit that was brought to the government by an ex-employee. The older case, however, arose from an OIG led investigation.

Final Thoughts

There are two clear takeaway points from these cases. First, exclusion violation enforcement cases can come to the attention of the government in several different ways. Second, the DOJ, OIG and CMS have a number of different enforcement options at their disposal! So remember, compliance is always the best option!

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Exclusion News

2014 In Review – OIG Crack Down on Exclusion Violations

I. CMPs doubled in OIG Exclusion Violations 2014

Exclusion Screening, LLC^SM dedicates a significant amount of time to examining the Office of the Inspector General’s (OIG) enforcement actions as they relate to exclusion violations. As a broad overview, in 2014 HHS-OIG imposed $10.54 million in Civil Monetary Penalties (CMPs) on providers that “knew or should have known” one or more of their employees or vendors was excluded from participation in the Federal health care programs. Most noteworthy, this number more than triples the $3.26 million in CMPs collected in 2013 and is the highest amount collected in the last five years.

In 2014, the OIG cracked down on many different types of providers. The OIG’s focus varied from pediatricians to large hospitals to home health organizations. However, the OIG specifically targeted nursing homes, which totaled a quarter of all exclusion enforcement actions in 2014. While nursing homes were also the most highly targeted industry in 2013, the OIG doubled the number of enforcement actions against nursing homes for exclusion violations in 2014.

II. 2015 Likely to See Increase in OIG Enforcement Action

Do these higher CMP amounts and increased enforcement actions mean there were simply more bad actors in 2014 than 2013? Likely no. These increases indicate that the OIG has identified an area ripe with exclusion violations and chose to target this sector. In fact, in its 2015 Work Plan, the OIG specifically mentions that fraud is prevalent in home health agencies and pledged to determine the extent to which home health agencies are employing individuals with “potentially disqualifying” criminal convictions.

Are specific areas of the United States more vulnerable than others for exclusion related violations? No. In fact, the OIG enforcement actions are not localized to one particular state or geographic area. The 60 exclusion enforcement actions in 2014 spanned 32 states. Texas took the lead with 6, and California followed closely with 5. Utah, North Carolina, and Ohio each had 4 enforcement actions. Furthermore, smaller states like Vermont and Iowa were not far behind with 3 and 2 enforcement actions.

III. Monthly OIG Exclusion Screening Is Essential

From this data, we can conclude that no matter the size, location, or industry, providers and health care organizations must be checking all their employees and vendors for exclusions against the LEIE, SAM, and state lists monthly. The OIG is not slowing down enforcement of exclusion violations. The OIG posted its first exclusion action of 2015 with a CMP collection of $431,041.28 for one excluded employee. Conducting proper screening may seem burdensome, but Exclusion Screening, LLC^SM can help your practice comply with state and federal exclusion screening obligations at a low, fixed price. Contact us for a free consultation at 1-800-294-0952 or fill out our online service form, found below, today.

Read more about OIG Exclusions by clicking here!

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Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.

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