Biggest Mistakes With Sanction Screening
With the Office of Inspector General, CMS, and State Medicaid Agencies all calling for increased and more frequent sanction screening, it is not surprising that providers responded by placing more emphasis on their efforts. This has become a costly effort, whether done internally or contracted out to a vendor. Furthermore, in some cases, particularly with hospitals, there are cases where this effort may have gone too far. It is increasingly common for organizations to screen individuals and entities unnecessarily and in some cases counter-productive or worse.
The most common examples are excessive screening (1) against the General Services Administration System for Award Management (SAM) [formerly the Excluded Parties List System (EPLS)]; and (2) of physicians who refer patients to the hospital, but are not employed by or have staff privileges.
General Services Debarment Data
For the GSA database, there are several difficulties associated with sanction screening:
- The design/purpose of the GSA data is for government agency use only
- Relatively few health care providers are a Federal government agency, or a grantee
- GSA provides no guidance as to how to resolve a potential hit
- GSA data lacks identifiable information for easy verification, whereas the OIG LEIE sanction screening has verification tools to assist with possible hits
- Many administrative debarments are only advisory and can be waived by agency heads
- There is no explanation where to draw the line in the sanction screening of contractors and vendors and even smaller hospitals may have many thousands of them
- GSA “hits” are common, legitimate ones are very uncommon
- Confirmed GSA hits provide little ground for terminating a contract, yet can’t be ignored
- Technical difficulties for GSA transition from EPLS to SAM has complicated it use
Screening of Physicians
The screening of physicians who are not on staff or have staff privileges at a hospital is another problem. Neither CMS, nor the OIG call for such screenings. There are many problems in trying to screen these physicians, including:
- There may be thousands of different physicians from time to time referring a patient to a hospital where they have no personal contact; and the cost of screening all of these and trying to resolve potential hits can be an expensive proposition.
- Often, the physician who refers a patient to a hospital may not be from the area, be personally unknown, or have never referred a patient before and may not do so again. It is very common for retired persons who spend much of their time in the winter in Florida or other warmer area to be referred by a local physician to the patient’s home area hospital.
- It is not unreasonable for the hospital receiving the patient to screen the doctor in advance of providing a service, nor will the hospital have any identifiable data on that physician.
- If there is a confirmed “hit” against the LEIE, there is little the hospital can do about it, other than write them to not refer anymore patients.
- If a sanctioned physician referral is made and the hospital knows about it, they are not entitled to payment by Medicare or Medicaid.
Suggestions
- In both types of situations described above, the best practice is to only screen those that you must and not try to do more than is required.
- It is difficult to see the logic in screening the local paper and ink supplier, florist, local newspaper, grounds keeping service, etc. If it is decided that screening against the GSA debarment data, then make a decision as to where you do draw the line as to who should be in the mix. The soundest practice for screening against the GSA debarment list would be to have a policy that requires screening any and all individuals and entities that provides medically related products or services. By filtering out those that do not meet that criteria would eliminate the great majority of vendors and contractors that are not relevant to health care, while maintain the spirit of screening against debarments.
- Trying to screen referrals from physicians who are not employees, on staff, or known to the hospital is not a good practice for the reasons noted above. Since there is no requirement or obligation to do such screenings, serious consideration should be given to avoiding doing them.
- If there are physicians unaffiliated with the hospital that are referring frequently, consideration might be to screen them; and if anyone is found on the sanction list to notify them to cease referring patients or the OIG would be notified.
