...but watch out if you hire any excluded physicians
...but watch out if you hire any excluded physicians
Even as the OIG expands its power to exclude providers under the 1996 HIPAA legislation, it’s also using its authority under the Balanced Budget Act to propose harsher penalties.
For starters, the government wants to crack down on hospitals that hire excluded doctors, according to rules proposed in the Sept. 2 Federal Register. "The OIG has been made aware of situations where individuals who have been excluded from Medicare or state health care program participation have been able to obtain (or retain) employment, staff privileges or other affiliation with various health care entities, and to render services that are ultimately paid for by the programs," says OIG.
The agency proposes a Civil Monetary Penalty of up to $10,000 against any provider that bills for the services of excluded employees. The exact fine would depend on whether the billing provider knew or should have known of the exclusion, any potential harm to Medicare or patients, and a history of prior sanctions.
To compound the burden, excluded providers are expected to work extra hard to notify beneficiaries of the exclusion. OIG wants to consider such notification when deciding whether to reinstate the provider. "We do not believe that notification only after the submission of a claim is adequate protection for program beneficiaries," says the agency.
OIG also would keep in mind whether the provider tried to submit any claims to any federal health care program. The upshot is that you had better make sure beneficiaries know of the exclusion and don’t try to submit claims on their own, says attorney Bill Sarraille, JD, of Arent Fox in Washington, DC.
In addition, an excluded person could no longer work for a federal agency that funds a federal health care program. Thus the Defense Department, which funds CHAMPUS, would no longer have any discretion to pay excluded parties for any services, nor may it pay them a salary. "In most instances, the effect of an OIG exclusion will preclude the employment of an excluded individual in any capacity by a federal or state agency," OIG notes. Many private payers also will not deal with anyone excluded by Medicare, adds Sarraille.
Other provisions of the proposed rules, which are open for public comment until Nov. 2, include:
- Stricter standards for managed care. HMOs also would get their share of attention. HMOs are not required to report adverse actions against suppliers and providers to the national Healthcare Integrity and Protection Data Bank, although such a requirement exists for private health plans and licensing boards. The proposed rules would impose a penalty of up to $25,000 on HMOs that failed to report adverse actions.
- Letting other agencies fend for themselves. OIG says it’s not practical to notify other HHS departments or other federal health care programs of exclusions. Those agencies would be expected to check the monthly exclusion list on OIG’s Web site, and then exclude those providers from their programs.
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