Effective Sanctions Screening to Minimize Compliance Risks

Overview

The Department of Health and Human Services Office of Inspector General (OIG) recommends that all organizations in the health care industry perform sanctions and exclusion screening on workforce members including employees, vendors, volunteers, and new hires. The purpose of these ongoing sanction checks is to determine if an individual or entity is excluded from participating in federal health care programs. They can also help organizations check if workforce members are currently participating in any fraud, waste, abuse or other illegal or improper conduct while working for or engaging with the organization. By conducting sanction checks on a regular basis, organizations can effectively monitor state and federal exclusion databases to avoid the risks associated with hiring or working with an individual or entity that is excluded from participating in federal health care programs.

Pre-Hire Sanctions Screening

One of the most effective sanctions screening methods to make sure that the workforce is not on any exclusion lists, and to help avoid the immediate and long-term risks of working with anyone on these lists, is to conduct pre-hire screening. The Compliance Department, Human Resources Department, Credentialing Department, Procurement Department, and other departments that handle hiring or contracting with new individuals and entities should conduct sanction checks prior to hire or contract to guarantee that no one entering the organization is excluded from participating in federal health care programs as a result of being involved in instances of fraud, waste or abuse. If the organization were to hire an individual who is on an exclusion list, the organization may not only face repercussions later on for hiring that individual, it could also unknowingly allow that individual to continue unethical behaviors or actions within the facility. By only hiring workforce members that pass the pre-hire screening, the organization can ensure that it is only hiring workforce members who are not currently excluded, which also helps mitigate the risks of engaging an individual or entity that cannot legally participate in federal health care programs.

Sanctions Screening Best Practices to Minimize Risks

In addition to pre-hire screening, there are other sanctions screening best practices that can help organizations conduct the most effective sanction checks, thus minimizing the risks of working with an excluded individual or entity. These practices include:

• Screen every individual and entity associated with the organization, no matter if they are paid or unpaid or whether they submit claims to Medicare or Medicaid. This can include employees, contracted businesses, vendors, suppliers, unpaid volunteers, board members, and executive management.
• Conduct screening on a monthly basis at a minimum. Federal and state exclusion lists are regularly updated to include new exclusion records, as well as to remove exclusion records of individuals and entities that have been reinstated in federal health care programs. As a result, the records included on these lists are likely to change from month to month.
• Screen names against the OIG List of Excluded Individuals and Entities and the General Services Administration System for Award Management list as a minimum requirement. Organizations can also screen against state Medicaid databases, the Office of Foreign Assets Control Specially Designated Nationals list, the Drug Enforcement Agency Criminal Cases Against Doctors and Administrative Cases Against Doctors lists, the Food and Drug Administration Debarment list, and others to generate more robust results.
• Ensure sufficient manpower to conduct necessary sanctions screening on a monthly basis. Some health care organizations rely on their own staff to carry out screening each month and resolve all possible matches. However, others have limited staff and/or the amount of names that need to be screened each month is too large to handle internally. When that is the case, health care organizations can seek an outside firm with a team of specially-trained employees to conduct sanction checks for them on a recurring basis using santions screening software.
• Include sufficient data about the individuals or entities being screened to yield the best results. It is suggested that organizations use the following data to yield the most accurate results: first, middle, and last names, date of birth, social security number, address, license number, Unique Physician Identifier Number, National Provider Identifier, entity name, and tax identification number.

In Review

Effective sanctions screening is key for health care organizations to maintain and hire only those individuals and entities who are not excluded from participating in federal health care programs due to involvement in fraud, waste, abuse, or other unethical behavior or actions. Organizations can avoid compliance risks as well as other liabilities by conducting pre-hire screening and by following sanctions screening best practices to produce the most robust and effective screening results. Combining these methods enables organizations to successfully monitor and prevent unethical compliance behaviors or actions in the workplace by guaranteeing that all workforce members and business entities associated with the organization are not excluded.

About the Author

Emily Tait is the Marketing and Proposal Manager at Compliance Resource Center. She has a master’s degree in professional writing from Carnegie Mellon University and has been part of the Compliance Resource Center team since April 2017.

About Compliance Resource Center

Compliance Resource Center has been leading the compliance industry since 2010 with our complete suite of solutions that are geared towards improving compliance program operations. Our solutions ensure that organizations regularly meet federal and state laws and supply the necessary resources to sustain long-term compliance.