To Avoid Potential Fraud, Payers Should Monitor the LEIE Regularly

by Cindy Gallee, JD, RHIA, CHC

Payers, especially those with contracts involving federal payments, should be monitoring their providers’ statuses under the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE). The OIG, part of the U.S. Department of Health and Human Services (HHS), is at the forefront of efforts to fight fraud, waste, and abuse in Medicare, Medicaid, and 300 other HHS services.¹ The OIG maintains the LEIE, which is a list of all individuals and entities excluded from receiving payment from federally funded health care programs. An individual or entity is listed on the LEIE if they have been convicted of fraud or abuse or have engaged in certain other misconduct. No federal health care program payment may be made for any item or service furnished by an excluded person, nor at the medical direction or on the prescription of an excluded person.

Penalties for non-compliance are severe and can include denial of payment for the services in question, repayment of paid amounts that are found to be improper, and civil monetary penalties of $10,000 for each item or service provided by the excluded entity. Also, if the excluded provider receives payment on improper claims, the False Claims Act could apply which imposes a fine of $5,500 to $11,000 per claim and treble damages. A provider would also risk exclusion from all federal programs.

In February 2015, a skilled nursing facility in Denver, Colorado was investigated by the OIG and found to have employed a nurse who had provided items and services to its Medicare and Medicaid beneficiaries, but who was listed as an excluded entity on the LEIE. The facility agreed to pay a civil monetary penalty of $242,434.92.

The OIG recommends that providers of healthcare screen for excluded persons monthly, when the LEIE is updated. However, payers may also want to screen for excluded providers as a factor in assessing the possibility for fraudulent claims. This is necessary for payers involved with administering federal contracts.

Context⁴ Healthcare, Inc. helps payers detect and eliminate potential fraud scenarios through industry-leading fraud, waste, and abuse solutions. FirstPass™ is Context’s robust claim editing solution that helps payers detect potential fraud before they pay the claim, and FWAHawk™ provides enhanced fraud identification and reporting capabilities. FirstPass™ is built around Context’s proprietary knowledebase with clinical edits developed over the course of 25 years, and automatically updated on a weekly basis. FirstPass™ with FWAHawk™ provides assistance for payers with exclusion screening by alerting the payer at the claim level when a provider is an excluded entity on the LEIE. Exclusion screening is a useful step in ensuring compliant payment of claims.

¹ About OIG | Ofice of Inspector General: https://oig.hhs.gov/about-oig/index.asp

For more on potential fraud, waste, and abuse: Identify Potential Fraud for Home Health Trends in E/M, Outliers & POS