Gary Cantrell Testimony: Failures to Report Adverse Licensing Actions Leads to Gaps in the OIG-LEIE

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Gary Cantrell Testimony

HHS/OIG Deputy Inspector General Gary Cantrell testified earlier this year that States are failing to report all of the adverse actions taken by their Licensing Boards. He suggested that the “manner and time of the [reported] notices” are unreliable. Cantrell attributed these concerns to the “voluntary” nature of State reporting obligations.[1]

I.  The Impact on Exclusion Enforcement

Gary Cantrell stressed the importance of the Office of the Inspector General’s (OIG) ability to exclude individuals and entities from participating in federal health care programs as a key administrative tool in fighting fraud. He emphasized that “adverse actions…enable us to identify numerous individuals who are subject to exclusion….” If the OIG, however, is not informed about these individuals in the first instance, or is informed in an untimely way, then it may never become aware that they should be considered for inclusion on the List of Excluded Individuals and Entities (LEIE). This creates a significant risk to the Medicare Trust Fund and thwarts the OIG’s ongoing exclusion enforcement initiative.

Mr. Cantrell stated that the issue arises principally due to the manner in which the information is reported. States report the adverse actions to the OIG on a voluntary basis. It can also be reported from individual State boards, general public notices of State board action, and from the working relationships between OIG exclusion analysts and other agencies. In addition to incomplete reporting, the timing and manner of the notices completely depend on each State’s licensing board. Cantrell recommended that Congress explore requiring more reliable and standardized reporting from State licensing boards to advance OIG’s ability to exclude providers.

II.  OIG’s LEIE and State Exclusion Registries May Differ  

A license revocation or suspension is grounds in of itself for a permissive exclusion. In addition, the facts that support such an action are often grounds for mandatory exclusions. Indeed, as a consequence of the board action and the underlying conduct, the individual or entity is almost certainly going to be included on the specific State Exclusion Registry. This can result, however, in an individual being excluded on a State Registry, but not on the OIG-LEIE!

III.  The Takeaway: Providers Shouldn’t Rely Exclusively on the LEIE

The takeaway for providers is twofold: 1) The LEIE and State Exclusion Registries can, and will, differ from time to time, and 2) In light of this, providers simply cannot rely exclusively on the OIG-LEIE as their sole exclusion screening tool. Providers should screen, at a minimum,[2] the federal lists (LEIE and SAM), their state exclusion list, and any unique additional lists that may be required by their State. 

 

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.



Ashley Hudson

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article. Contact the exclusion experts at Exclusion Screening, LLCSM today for a free consultation by calling 1-800-294-0952 or online.

[1] Testimony of Gary Cantrell, Deputy Inspector Gen. for Investigation Office of the Inspector General U.S Dep’t of Health and Human Servs.; “Medicare Program Integrity: Screening Out Errors, Fraud, Abuse” before the House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, 9 (June 25, 2014).

[2] The exclusion experts at Exclusion Screening, LLCSM automatically screen all State Exclusion lists and strongly recommend that this is a “best practice” for all providers. Our other blog posts on this site more fully discuss our reasons for this recommendation. 

Exclusion Databases: How Difficult Is Screening and Verifying?

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exclusion databases
I.  Which Exclusion Databases Do I Need to Screen?

The Office of Inspector General (OIG) recommends that you screen your employees, contractors, and vendors every month against the List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM). Your State Medicaid director mandates monthly screening of your State exclusion databases, in addition to the LEIE and, perhaps, the SAM.  In a number of states, when you enroll or re-enroll you have to certify that none of your employees or contractors are excluded from any Federal or State Healthcare Program. 

If your State happens to be Texas, you will have to certify that you have conducted an “internal review” to determine if any of your employees or contractors have been excluded from Medicare, any State Healthcare program, or from the CHIP program.[1] Unfortunately, each of the 40+ exclusion databases to be searched (the LEIE, SAM and 41 States) are “stand alone” exclusion databases that are unique in their composition, content and the way they can be screened.  This article discusses those differences and the problems associated with the exclusion databases.

II.  Screening the LEIE

The LEIE contains approximately 60,000 persons and is updated monthly. It contains identifying information such as the excluded individual’s name, date of birth, provider type, and other information. It is also searchable or downloadable. The LEIE allows a provider to perform a basic name search. It then provides a list of names that match your search. To determine if the potential match is your employee, the database verifies quickly by Social Security Number (SSN). The OIG describes the process in its May, 2013 Advisory Bulletin as a relatively simple one in which providers only have to “review each job category or contractual relationship to determine whether the item or service being provided is directly or indirectly, in whole or in part, payable by a Federal health care program.” If only it was as easy as the OIG makes it sound.

Although the LEIE is “searchable,” it only allows five names to be searched at a time. In addition, potential matches can only be verified individually by entering the social security number. While this is not a problem for a 10-person practice, the difficulty of checking and verifying increases exponentially with a practice of 100, 1000, or even a provider with 5000 employees, such as a hospital.

The alternative of downloading the LEIE database is equally problematic. Most providers simply do not have the capability to download the LEIE (which contains almost 60,000 names), and compare it with their own employee database in any reliable or economically viable way.

We also note that the LEIE’s matching criteria is not exact and often overlooks potential exclusions. For example, there is no mechanism built into the LEIE that will allow a search for “William Smith” to return matches for common alternatives such as “Bill,” “Will,” “Willie” or “Billy” Smith. Finally, one last significant issue is that the guidance by OIG ignores State screening requirements and regulations. 

III.  GSA-SAM

The System for Award Management (SAM) consolidated the Central Contractor Registry (CCR), Federal Agency Registration (FedReg), Online Representations and Certifications Application (ORCA), and Excluded Parties List System (EPLS) into a single database for federal contractors who were debarred, sanctioned, or excluded for contract or other fraud. The consolidation eliminated certain codes, reclassified others, and uses four exclusion classifications: Firm, Individual, Vessel, and Special Entity Designation (a catch-all phrase for an organization that is not considered a firm, individual, or vessel, but nonetheless needs to be excluded). 

The SAM consists of almost 126,000 excluded entities and providers. It verifies by EIN, CAGE Code, DUNS, NAICS, or PSC. Excluded individuals are verified by SSN. Similar to the LEIE, the SAM is either searchable or downloadable, but it also presents similar problems. For instance, the name search is limited and must be an exact match, so any slight variation will not return a match.

When verifying an excluded provider on SAM by SSN, you are directed to type your employee’s name and his or her SSN into the boxes provided. The database will then report whether the SSN and the provider’s name are a match in SAM. Unlike the LEIE, SAM matches the exact provider name[2] and SSN to the SAM database names and their associated SSNs. This is a big contrast to the LEIE, since SAM does not pull up a list of every person who matched your query for you to verify individually. As with the LEIE, downloading the entire list of 126,000 names and matching it with a large employee list is beyond the capabilities of most providers.

IV.  The States

Even though the States have much smaller exclusion databases or lists, they are even more challenging than both the LEIE and the SAM when it comes to screening and verifying.[3]  Each listing is unique and comes in different document formats, with different fields, and contains different information. As a result of these differences, cross-checking names between State and Federal databases is a significant obstacle to overcome.

When it comes to verification, unlike digital verification as with the LEIE or SAM, most states verify excluded providers by email with the provider’s last four digits of his or her SSN.[4]  Usually, the email for the State’s contact is listed on the State’s exclusion databases website or on the list itself. However, it is not unusual for there to be difficulty in tracking down the responsible person, different persons depending on the nature of the exclusion, or nobody listed at all. In those instances, phone skills and perseverance are required to find the right person to talk to. It can also take from around twenty minutes to several weeks to receive a response as to whether the names and SSNs listed are a match.

V.  Screening and Verifying All State Databases

We address why all State and Federal databases should be screened in other blog postings, but it is imperative to note that providers should screen and verify all State databases. Section 6501 of the Affordable Care Act (ACA) mandates that if a provider or entity is excluded under any State Medicaid database, then that provider or entity should be excluded from participating in all States.[5] Accordingly, providers should know how to perform exclusion checks of all State databases. 

VI. Conclusion

While Exclusion Screening, LLCSM has compiled all 40+ State and Federal exclusion databases into our own searchable database for checks and verifications, this step is beyond the IT ability of most providers due to the variety of list formats (PDF, Word, Excel); the differences in information provided within each of the exclusion databases (i.e., some States provide first and last names, while other states provide first, last, and middle names; additionally, some States parse the names into different excel fields, while others leave the entire name in one field); and the constant (usually monthly) updates to each of the State exclusion databases or lists. 

You can see why the checking and verification process is not as simple as OIG and the States may have suggested. Even though the process is time consuming, it is critical that providers check employees, vendors and contractors against all 41 lists. Failure to properly screen employees and vendors could result in CMP liability of up to $10,000 for each item or service furnished directly or indirectly by an excluded individual. Instead of overburdening your current employees, contact Exclusion Screening, LLCSM today by filling out the form below for a free consultation and assessment of your screening and compliance needs.

 



 

Erin Archer exclusion databases

Erin Archer is the author of this article. Feel free to contact us at 1-800-294-0952 or online for a free consultation.

[1] See, e.g., Texas Admin. Code, Rule § 352.5.  An even more exacting obligation is found in Louisiana where provider agreements require applicants to certify that no employees or contractors are currently, nor have ever been, excluded from Medicare, Medicaid or other Health Care Program in any state!

[2] Unlike the LEIE and some State databases, SAM has only one designated field for the provider’s “name,” instead of parsed “first,” “last,” and “middle” name field options.

[3] As of this posting, there are thirty-seven separate state listings.

[4] California and Florida do not verify by SSN.

[5] 42 U.S.C. 1396(a) (2012). Whether an exclusion by one state actually “excludes” an individual from all states or makes him “excludable” from all states is an open question at present, but why take the chance of hiring a person who has been excluded in another State if you don’t have to?

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