Chief Compliance and Ethics Officers Health Care

OIG Exclusion List linked to CMS?

  • 1.  OIG Exclusion List linked to CMS?

    Posted 10 days ago
    I seek assistance.

    We employ a provider who shares the name of an individual who appeared on the OIG Exclusion list last month.  We learned of this when Walmart refused to fill her scripts.  The next day Walgreens followed suit, and CVS the next day.  Now all pharmacies will not.

    I've spoken to 25+ people between pharmacy corporate offices, OIG, CMS Washington and regional.  The information on the OIG website is correct.  But, that person (she is currently in prison) is not our provider (different NPI, DOB, Address, SS#).  The pharmacies tell me that CMS has the provider excluded.

    Some conversations lead me to believe the Lexis Nexis pulls data from many sources, including OIG and provides the information to CMS.  During the process the third party vendor linked two people as one.  The sheer negligence baffles me.

    Has anyone encountered this?  Who did you contact to correct it?  I assume that claims will start being rejected soon.  Any guidance from your experience is greatly appreciated.

    Matt

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    Matthew Mayo CHC
    Grants & Compliance Coordinator/Privacy Officer
    North Florida Medical Centers, Inc.
    Tallahassee,FL
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  • 2.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    I think that this is going to shape up to be a nice discussion...thanks for posting.  Years ago I did audits of names on the LEIE and found that between 10 - 15% of the names listed are listed in error for various reasons.

    Once the list migrated over to SAM.gov, I stopped down the audits because when I started doing audits between LEIE and EPLS...the results were even worse.

    Unfortunately, the pharmacy is likely going to follow its policy and not process a script for a provider that is listed as excluded.  You may get lucky and see if someone will be willing to make an exception and do some type of override...but given the risk involved if something were to go wrong...not likely.

    Please keep us posted!

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    ► The CSG Has Begun! ◄
    --------Frank Ruelas---------
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  • 3.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    Matthew, how frustrating!  I haven't experienced this with OIG, but I have experienced wrong information in other areas, such as insurances, PECOS, NPI, etc., and it always seems quite difficult to get to the correct person and actually get the information corrected. One thing you may want to check is if that physician is also on your state's Medicaid exclusion list.  An OIG rep once told me that names on the State's exclusion list eventually made its way to OIG's list.  Good luck! I hope someone has some information that will be helpful to you.

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    Cinda
    Compliance/Ethics & Privacy Director
    Ohio
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  • 4.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    I'm going to email Jon from VerifyComply as he may have some good feedback to share.

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    ► The CSG Has Begun! ◄
    --------Frank Ruelas---------
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  • 5.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    Edited by Jon McCollum 9 days ago
    Hi Matt,

    The good news is, I suspect your Medicare claims will continue to be paid as it's highly unlikely that CMS is using a third party data aggregator to scrub claims.

    It's not unusual to see issues with data aggregators, and in the fine print you'll often see mention of an error rate.  We use several different aggregators (LexisNexis is one) when performing investigations & correlation studies on possible matches.  Where we benefit from having time to evaluate/escalate/reason whether the data being returned is reliable, the prescribing/ordering/referring provider scrubbers rely on fast computer-only driven insights – with accuracy being a tradeoff.

    With that being said, I do wonder whether your party's NPI could be associated with another excluded provider (perhaps with a different name).  These scrubbers are usually driven by NPI as it's a standardized and unique identifier (unlike a name search).  If you'd like to contact me offline with the name and NPI in question, I'd be happy to check our databases for clues.  If this suspicion is true, I'd bring the issue to the agency in question to correct their data.  If the NPI is clear and the pharmacies can't override/release the order from their scrubber (I suspect they can, but might not know how), I'd probably escalate to their compliance office.  If that doesn't work, or perhaps in tandem, you can also try to find out what program(s) these pharmacies are using to scrub the ordering/prescribing docs and contact the software platform's compliance department. 



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    Jon McCollum
    jon.mccollum AT verifycomply.com
    Verify Comply
    www.VerifyComply.com
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  • 6.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    Thank you for the comments and advice.

    As of now, I have confirmation from OIG and CMS that our provider has no restrictions connected to her.  They both tell me our provider is perfectly clear.

    Now, where are the pharmacies obtaining their data?  Every single pharmacy is denying her scripts claiming 'Exclusion List.'

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    Matthew Mayo CHC
    Grants & Compliance Coordinator/Privacy Officer
    North Florida Medical Centers, Inc.
    Tallahassee,FL
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  • 7.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    Matt,

    Might you be willing to elaborate on how this was confirmed with OIG & CMS?


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    Jon McCollum
    Verify Comply
    www.VerifyComply.com
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  • 8.  RE: OIG Exclusion List linked to CMS?

    Posted 9 days ago
    Edited by Jon McCollum 9 days ago
    I ask because what if your provider's NPI is listed under someone else's name?

    If you call the OIG and ask if your Dan Smith with NPI 1234567890 is excluded, they'll confirm he's not - but remember their process.  They'll search for Dan Smith (by name) and then see the Dan Smith listed on the LEIE has a different NPI than your Dan Smith.

    But what if NPI 1234567890 was on Jane Doe's exclusion record in the LEIE?  Even though the name is different, a software program could still find a match on the NPI.

    If you haven't already done so, you'll likely want to download the full LEIE/SAM and then search for the NPI in question.

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    Jon McCollum
    Verify Comply
    www.VerifyComply.com
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  • 9.  RE: OIG Exclusion List linked to CMS?

    Posted 4 days ago
    ​Thank you for this discussion. Sounds like a very frustrating experience, especially for the patients impacted!
    Interestingly, we are trying to make decisions if we continue to use a company, or perform our own monthly LEIE checks on our providers. Money v. time.  I'll post if we determine an accuracy problem.  So far we have not had anyone come up (in the final analysis) as excluded.

    One very difficult problem we have is checking the VENDORS we do business with.  My controller is not clear on which databases need to be checked.  Sometimes we have TIN, but to check the alias company names, the owners, etc. is apparently confusing and inaccurate.  Can someone share thoughts on that? SAM v. LEIE? Do we need to check other registration databases? None of it seems clear, and I am of little assistance to her.
    Thanks in advance.

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    Marcia Rasch PhD,CHC
    Corporate Compliance Officer
    HealthSource of Ohio
    Milford,OH
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  • 10.  RE: OIG Exclusion List linked to CMS?

    Posted 3 days ago
    ​Marcia,
    Though there seem to be a number of opinions on which lists to check vendors against we have chosen, perhaps out of an abundance of caution, to check them against LEIE, SAM and the Office of Foreign Assets Control (OFAC) lists.
    We use a vendor to handle this process and check all vendors each month. We have been very pleased with our vendor both as to the results and the costs.
    You can email me or call if you'd like to discuss further.
    Charlie

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    Charles Colitre BBA, CHC, CHPC
    Compliance & Privacy Officer
    Crystal Clinic Orthopaedic Center
    Akron,OH
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  • 11.  RE: OIG Exclusion List linked to CMS?

    Posted 3 days ago
    Hi Marcia,

    The short answer is, it depends.  Where you operate, from who do you receive payments, contractual obligations, what type of business, etc. – all can drive different answers into to who and which sources should be checked.

    I generally advise clients to monitor all vendors, then if there's a match, you can then determine if it matters.  It typically requires less time to monitor all than parsing out which vendors should/should not be searched.  If you find an exclusion monitoring software vendor with a flat rate pricing structure, you're not pinged for the extra volume.

    We can go down the SAM/LEIE exclusion/debarment rabbit hole offline if you'd like.  Feel free to reach out.

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    Jon McCollum
    Verify Comply
    www.VerifyComply.com
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