On these pages previously we’ve discussed HRSA’s Compliance Manual’s Chapter 5 mandating verification of credentials for Licensed Independent Providers (LIPs), Other Licensed Professionals as well as any other employed staff or even volunteers in an effort to mitigate patients seeing patients who could cause harm. Primary or other source (e.g., state medical or other society performing) verification is not just recommended. It is required.

What happens if you perform and document initial diligence only to find later that those initial findings were inaccurate or fraudulent? Short answer from a compliance perspective, going back to Certified Federal Register language from 1998, detect the problem and mitigate/correct issues as quickly as able. ANY issue from incorrect coding/billing to determining a staff person is not adequately or legally licensed or credentialed, it is the employer’s obligation to take swift corrective action as soon as the problem is identified.

On January 25, 2023, the United States Attorney’s office for the Southern District of Florida announced two dozen charges arising from falsely obtained nursing degrees. Several Florida schools allegedly provided diplomas and transcripts (for people all over the country) affording them ability to sit for state nursing boards. From a coding and billing perspective, this is problem. From a patient safety issue, it is significantly more disconcerting.

Aside from patient safety concerns, liability exists inasmuch as the Office of the Inspector General (OIG) disallows Federal (i.e., Medicare, Medicaid (10-50% federally funded), Title X) reimbursement to an entity employing a staff person on the exclusion list. Mandatory exclusions from participation in all Federal health care programs (i.e., no leniency) are required for individuals and entities convicted of the following:

• Medicare or Medicaid fraud

• Any offenses related to delivery of items services under Medicare, Medicaid, SCHIP, or other State health care programs

• Patient abuse or neglect

• Felony convictions for other health care-related fraud, theft, or other financial misconduct

• Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

 Permissive (i.e., discretionary) exclusions include (but are not limited to): 

• Misdemeanor convictions related to health care fraud other than Medicare or a State health program

• Fraud in a program (other than a health care program) funded by any Federal, State or local government agency

• Misdemeanor convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation,

• Surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity

• Provision of unnecessary or substandard services

• Submission of false or fraudulent claims to a Federal health care program

• Engaging in unlawful kickback arrangements

• Defaulting on health education loan or scholarship obligations

• Controlling a sanctioned entity as an owner, officer, or managing employee

 That last bullet is a particularly tough pill to swallow.  Just being employed somewhere at which someone (anyone) did something to bring sanction and that person is penalized... talk about one bad apple.

The ONLY way to know if someone is on this list is to check. It is easy enough to have a health center staff person check the OIG exclusion list.  This should occur at least monthly. The other option is to engage a firm to which outsourced OIG search function is performed or with one for all credentialing and enrollment activity.

 Have questions about this or other elements of health center credentialing and enrollment? Get in touch with PMG Credentialing. We are health center experts and stand ready to help.