Author: Dale Sahlberg- 1 -
The Office of the Inspector General (OIG), under a Congressional mandate, established a program to exclude individuals and entities affected by these various legal authorities (contained in sections 1128 and 1156 of the Social Security Act) and maintains a list of all currently excluded parties called the List of Excluded Individuals/Entities (LEIE). Providers may be excluded for a multitude of reasons, the most common of which are license revocation or suspension, program-related convictions, patient abuse or neglect and defaults on health education loans.
Exclusions and Debarments
If you are participating in or billing a Federal health care program, you generally may not employ orcontract with an excluded or debarred individual or entity. No payment will be made by any Federalhealth care program for any items or services furnished, ordered, or prescribed, directly orindirectly, by an excluded or debarred individual or entity. Federal health care programs includeMedicare, Medicaid, and all other plans and programs that provide health benefits funded directly orindirectly by the United States (other than the Federal Employees Health Benefits Plan).
If a hospital employed or did business with an excluded individual and filed a claim with a federal health care program, it would be subject to a penalty of up to $10,000 for each item of service improperly claimed and an assessment of up to three times the amount improperly claimed.
The HHS Office of Inspector General is responsiblefor excluding individuals who have participated orengaged in certain impermissible, inappropriate,or illegal conduct. The OIG’s List of ExcludedIndividuals and Entities (LEIE) provides informationon all individuals and entities currently excludedfrom participation in the Medicare, Medicaid, andall other Federal health care programs. The LEIE,along with other information pertaining to OIGexclusions, may be accessed at the Internet.
By adding a field to the PRDOC profile, a hospital can detect when an excluded doctor was selected and issue a warning.
A)Create a field to store the flag for the excluded doctor –
B) Add a data pool listener for the field you want to monitor; in this case it is the admitting doctor field “C0824” -
C) Create the LEIE message panel with a CLOSE button -
As soon as the doctor field was filled in, a data pool listener detected that data was entered and activated a GUI clause to check for the LEIE indicator.
In this example, the doctor was excluded by the OIG and the registrar was immediately notified of the exclusion in the message panel and in a line 24 message at the bottom of the screen. The registrar then is responsible for checking the insurance plans and other indicators to see if the case pertains to any Federal health care program.
The List of Excluded Individuals/Entities (LEIE) is available in several different versions from the OIG and is _.dbf files zipped into self-extracting executable files.
The updated LEIE is a complete database file containing all exclusions currently in effect. Individuals and entities who have been reinstated are not included in this file. Each month a new updated LEIE is posted by the Office of the Inspector General (OIG).
Now a hospital, by checking the LEIE and maintaining the PRDOC profile, can meet the Office of the Inspector General (OIG) requirements.