If you employ medical professionals such as nurses and physicians, it is important for you to understand medical sanctions. It is even more important if your organisation administers federal healthcare programs such as Medicare and Medicaid.

Failure to understand medical sanctions can set you up for fines, suspension from federal healthcare programs, and even jail time – if you violate them. Below is a brief explanation of medical sanctions. To start off, let’s begin with the definition:

What Are Medical Sanctions?

Also referred to as “healthcare sanctions”, medical sanctions are exclusions which are levied against certain individuals or entities from participating in federal healthcare programs. The individuals are usually healthcare professionals. The entities are usually organisations which provide healthcare-related services.

Any individual or organisation which is excluded from federal healthcare programs is said to have been “sanctioned”. Sanctioned individuals and entities are barred from participating in federal healthcare programs such as Medicare and Medicaid.

As such, any organisation which administers Medicare or Medicaid barred from having business engagements which such individuals or entities. For instance, it is illegal to hire sanctioned individuals. An employer who hires sanctioned individuals can face fines, suspension from Medicare/Medicaid, and even jail time.

Why Medical Sanctions?

Medical Sanctions are aimed at excluding people with questionable backgrounds from participating into federal healthcare programs. The exclusions are mandated under sections 1128 and 1156 of the Social Security Act. Generally speaking, people tend to get sanctioned after having committed some form of violation.

The most common violations which can get someone sanctioned include Medicare/Medicaid fraud and patient abuse or neglect. Other violations include felony convictions arising from healthcare fraud or theft, financial fraud, as well as the illegal manufacture, distribution and dispensing of controlled substances.

An individual can also get sanctioned if their license has been suspended or revoked for professional misconduct, or if they have been convicted of a non-medical related felony. An organisation which hires a sanctioned individual, or a person who manages a sanctioned entity can also get sanctioned.

Who Carries Out The Sanctions?

In most cases, medical sanctions are administered by the Office of the Inspector General (OIG) in the US Department of Health & Human Services. The OIG is tasked with excluding individuals from federal government programs.

The OIG doesn’t carry out exclusions arbitrarily. It follows a strict guidelines stipulated under sections of the Social Security Act. For starters, every exclusion begins with a thorough investigation of an individual or entity to ascertain that their conduct warrants exclusion.

Secondly, before excluding an individual or entity, the OIG sends them a Notice of Intent to Exclude. Upon receiving the notice, an individual or entity is presented with an opportunity to clear their name. They are only sanctioned when they fail to satisfactorily clear their name.

Even then, OIG sanctions are not final. Any individual or entity who is dissatisfied with the OIG exclusion can appeal to an HHS Administrative Law Judge, an HHS Departmental Appeals Board or a federal court.

There is one thing which is important to note: the OIG isn’t the only body which excludes healthcare practitioners from federal programs. Other government department can also carry out exclusions. For instance, the General Services Administration (GAS) can suspend or revoke the licenses of healthcare practitioners. The Food and Drug Administration (FDA) can also suspend practitioners who commit certain professional violations. However, irrespective of the source, the OIG is agency which ensures that the exclusions are implemented.

What Are Sanction Lists?

A discussion of Medical Sanctions isn’t complete without a look at “sanction lists”. In a nutshell, a sanction list is simply a list of sanctioned individuals or entities. It is usually a list or database which contains the names of individuals or entities who are barred from federal healthcare programs.

The purpose of Sanction Lists to make it easier for employers to avoid hiring sanctioned individuals. To identify whether or not an individual is sanctioned, it is a matter of checking whether their name is in the sanctioned list.

There are numerous medical sanction lists. Some estimates put the number of lists up to 36. However, two most popular ones are the List of Excluded Individuals and Entities (LEIE), and the Fraud and Abuse Control Information Systems (FACIS).

The LEIE is published by the OIG. It contains the names of individuals and entities which have been sanctioned by the OIG. It is updated monthly, and is the primary resource used for identifying sanctioned individuals.

The FACIS is a database which compiles information from different healthcare sanction lists. It compiles sanction lists published by the OIG, GAS and FDA. It also tracks exclusions, debarments, reprimands and suspensions.

How To Avoid Hiring Sanctioned Individuals

The penalties for hiring sanctioned individuals are extremely steep. For instance, the OIG can fine an organisation up to $10,000 per day worked by a sanctioned individual. Suspend them from federal health programs, revoke their license and even recommend jail time for their leaders. The way to avoid such penalties is to avoid hiring sanctioned individuals.

The best strategy is through medical sanction checks. These checks are aimed at identifying whether or not an individual is on the sanction lists. To make sanction checks effective, it is advisable to conduct them at least three times.

Before Hire

Before hiring any healthcare professional, it is an absolute must to conduct a sanction check. This is the only way to prevent hiring sanctioned individuals.

Before Appointment

Sanction lists are updated periodically. There is also a time-lapse between the time an individual is sanctioned, and the moment their name appears on the list. As such, between the time of hire and appointment, it is possible that an individual’s name could have appeared on the list. As such, before giving an employee a contract, it is necessary to carry out sanction checks on them.

Periodically

Sanction lists are updated periodically. As such, as part of the due diligence, it is important to run the names of employees through the lists periodically. This is the only way of assuring that those who slipped through the pre-employment checks are weeded out.

In a nutshell, understanding medical sanctions is important for any organisation which employs healthcare professionals. The above information explains the basics. If you desire to get medical sanctions explained further, the best option is to contact a background screening company which provides medical sanctions checks.