For any healthcare service provider who participates in federal healthcare programs like Medicare and Medicaid, the concept of medicals sanctions is critical. The reason for this is simple: violating medical sanctions can prove extremely costly.

The penalties for violations can range from steep fines (e.g. $10,000 per day per violation) to discontinuation from Medicare/Medicaid and even jail time. Therefore, if you are a Medicare or Medicaid health service provider, you need to steer clear of medical sanctions.

To steer clear of medical sanctions, you need an effective strategy to avoid violating medical sanctions. That is where this medical sanctions checklist comes in handy.

The purpose of this checklist is to outline all the major aspects of a medical sanctions strategy. If you already have a strategy, you can use this checklist to evaluate it. In case you don’t have one, you can use the items in this checklist to create one.

This medical sanctions checklist is divided into two major parts. Part 1 deals with medical sanctions checks. Part 2 deals with medical sanctions compliance.

The major items on the checklist are presented in a question format. The questions require simple YES or NO answers. So, by simply reading through the checklist, you can easily identify any gaps in your medical sanctions strategy.

Part I : Medical Sanctions Checks

The easiest way to violate medical sanctions is by hiring sanctioned individuals. The most effective way to avoid hiring such individuals is through medical sanction checks. There are five important aspects of medical sanctions checks:

  • timing (i.e. at what point in an HR decision making process you conduct the checks)
  • types of sanction checks
  • hiring a sanctions check vendor
  • sanctions check compliance
  • sanctions check reports
  1. Timing:

  • Do you conduct pre-hiring medical sanctions checks?
  • Do you conduct pre-appointment medical sanctions checks?
  • Do you conduct pre-promotion medical sanctions checks?
  • Do you conduct ongoing medical sanctions checks?

NOTE:

Pre-hiring sanction checks: are conducted before hiring. They are part of the applicant screening process.

Pre-appointment: are conducted after hiring, but before appointment. The reason for this is that someone’s name can appear on a sanction list after the pre-hiring check.

Pre-promotion: are conducted before any major promotion.

Ongoing: are carried out on all medical staff periodically e.g. annually, bi-annually, quarterly or monthly. The reason for this is that sanction lists are updated periodically. This check is to identify any staff members who have been placed under sanction.

  1. Types of Checks:

There are two types of medical sanctions checks. There are Office of the Inspector General (OIG) sanctions checks and the Office Foreign Assets Control (OFAC) checks.

2-A: OIG Sanctions Checks

OIG Sanctions Checks are aimed at identifying individuals who have been sanctioned by the OIG of the US Department of Health & Human Services. These individuals are barred from participating in Medicare and Medicaid for a number of reasons ranging from a history patient abuse to criminal convictions.

Do you carry out OIG Sanctions Checks?

Do you check for individuals using the following medical sanctions lists?

  • List of Excluded Individuals and Entities (LEIE)
  • Fraud and Abuse Control Information Systems (FACIS)
  • US General Services Administration (GSA) Exclusion Lists: i.e. the Excluded Persons List System (EPLS), and System for Award Management (SAM)
  • States medical sanctions lists (around 32 states have their own sanctions lists)

2-B: OFAC Sanction Checks

The Office of Foreign Assets Control (OFAC) of the US Department of Treasury monitors decides which foreign individuals or organisations are permitted to conduct business in the US. Specifically, certain individuals are banned from conducting business in the US. OFAC Sanction Checks are aimed at identifying such individuals.

Do you carry out OFAC Sanction Checks?

Do you check for individuals using the following sanctions lists?

  • Specially Designated Nationals and Blocked Persons List
  • Foreign Sanctions Evaders List
  • Iran Sanctions Act List
  • Sectoral Sanctions Identifications List
  • Country Specific Lists (e.g. Syria, Iran, Russia, Zimbabwe)
  1. Hiring A Sanctions Check Vendor

If you intend to contract your medical sanctions checks to a vendor, then you need to select the right vendor. A simple criteria for selecting the best medical sanctions check vendor is outlined below.

  • Is the vendor a member of the National Association of Professional Background Screeners (NAPBS)?
  • Is the vendor NAPBS accredited? (only 62 of the 700 NAPBS members are accredited, so this is a big deal)
  • Does the vendor have experience in conducting medical sanction checks? (a minimum of 5 years experience is a basic requirement)
  • Does the vendor have a clean track record? (i.e. no lawsuits or class actions resulting from their background checks)
  • Does the vendor conduct sanctions checks on both national and state lists?
  • Does the vendor adhere to Fair Credit Reporting Act (FCRA) guidelines?
  1. Compliance of Sanction Checks

If your medical sanction checks are carried out by a screening vendor, then it has to adhere to FCRA guidelines. To ensure FCRA compliance, these are the things you should consider:

Do you offer applicants/employees “stand-alone disclosures”?

Do you obtain written authorizations from applicants/employees before conducting the checks?

Do you send pre-adverse action notices to applicants/employees?

Do you send adverse action notifications to applicants/employees?

  1. Contents of A Sanctions Check Report

Does each medical sanctions check report contain the following sections?

  • Start date of sanction
  • Expiry date of sanction
  • Location of Violation
  • Section of Code Violated
  • General Description of Violation

Part II: Medical Sanctions Compliance

One of the commonest sources of medical sanctions is committing Medicare or Medicaid fraud or breaking healthcare laws. Unlike other forms of fraud, it is possible to commit healthcare fraud without even realising it. To prevent healthcare providers from unwittingly committing fraud or breaking laws, the OIG has published Compliance Guidances.

These Guidances are designed to help you design a sanctions compliance program. Each Guidance is designed for specific kinds of services providers e.g. hospitals, individual physician practices, medical equipment suppliers, clinical laboratories, Medicare+Choice organisations, Hospices, and so on.

  1. Do you have an OIG compliance program?
  2. Does your program have the following?
  • Well written policies, procedures and standards of conduct
  • A plan for training staff on the policies, procedures and standards of conduct
  • The designation of “compliance officer” or any other person in charge of implementing compliance activities
  • A mechanism through which whistleblowers can report violators anonymously
  • A mechanism for investigating violations
  • An internal system to for correcting, reprimanding or retraining violators
  • A monitoring, evaluation and auditing system to track compliance
  1. Does your compliance program meet the unique characteristics of your health service? (To find OIG Guidelines specific to your service, please visit http://oig.hhs.gov/compliance/compliance-guidance/index.asp)

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