Biggest Mistakes With Sanction Screening

With the Office of Inspector General (OIG), 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, it is counter-productive or worse.

The most common examples are excessive screening (1) against the General Services Administration (GSA) 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 do not have staff privileges at the hospital.

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 List of Excluded Individuals/Entities (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, but 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 have complicated it use.

Screening of Physicians

The screening of physicians who are not on staff or do not 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; 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, may be personally unknown, or may 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, and the hospital will not 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 to them not refer anymore patients.
• If a sanctioned physician referral is made and the hospital knows about it, it is 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 an organization decides to screen against the GSA debarment data, then make a decision as to where to draw the line regarding who should be in the mix. The most sound practice for screening against the GSA debarment list would be to have a policy that requires screening any and all individuals and entities that provide medically related products or services. Filtering out those that do not meet that criterion would eliminate the great majority of vendors and contractors that are not relevant to health care, while maintaining 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 them.
• If there are physicians unaffiliated with the hospital that are referring frequently, consideration might be to screen them. If anyone is found on the sanction list, they should be notified that they must cease referring patients or the OIG would be notified.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.