Excluded Persons = Big Dollars!

By Chuck Humphrey, B.A., EMT-B, CAC, CADS*

One Person, $371K!

The healthcare compliance landscape is littered with all kinds of seemingly small incidents that turn into embarrassing big paybacks and public relations nightmares.

Such was recently the case when a large hospital system in California agreed to pay $371,000 in a civil monetary payment (CMP) settlement over the employment of an excluded person.

Excluded Persons = Big Dollars!

Define Excluded Person

You’re probably thinking; “Define excluded person.”

The Federal Department of Health and Human Services Office of Inspector General (HHS OIG) maintains the List of Excluded Individuals/Entities (LEIE). This list includes the names of people and organizations who have committed some proven fraud and/or abuse within the Medicare and/or Medicaid system such that they are banned from billing to Medicare or Medicaid for a specific time frame or they can be totally banned from ever gaining billing privileges.

Any healthcare organization that receives Federally-generated reimbursement dollars and employs someone who has been excluded or has such a person acting on their behalf can be penalized, including having their billing privileges revoked. This includes people in direct patient care as well as those who work in office operations at a health care provider facility or other entity.

Penalties and Paybacks

In addition to the potential for being banned from billing, the healthcare provider or supplier must refund 3 times the value of the claim plus face civil monetary penalties ranging from $11,803 to $23,607 PER OCCURANCE under the Federal False Claims Act.

And, those CMP values increase each year!

The California hospital system that failed to vet out the excluded person and hired the individual as a provider who cared for patients for nearly two years, amassed the payback and penalty. One person not properly vetted caused all of this damage.

Why haven’t I heard of this exclusion list?

Since I’m not looking at you, please honestly raise your right hand and ask the question, under oath… Why haven’t I heard of this exclusion list?

Actually, I hope you’re not asking this question; but if you are asking it then it’s time to understand just what you need to do.

But if you are asking it then your compliance risk just went through the roof. Potentially, you could have individuals on your active roster, running EMS calls who are banned from having any connection to the EMS world. Potentially, every EMS call they run can be considered a false claim when billing to Medicare or Medicaid and those reimbursement dollars should be repaid to the Feds.

Impact to EMS

So, we’re in a pandemic. EMS providers are few and far between. You hire someone quickly and push them onto the ambulance to run calls. Mission accomplished! The schedule that looked like Swiss cheese just yesterday, is finally full.

You acted so fast to hire a body to fill a hole, that you failed to check the LEIE database and 3 months later you receive a nasty-gram from the Medicare contractor that your new hire once worked at another ambulance service and was caught committing fraud.

Now this paramedic has been on the truck doing 12 hour shifts over a 90-day period. Out of those 90 days, he has averaged 5 EMS runs per day and worked 60 days. That’s 300 total runs.

Because sixty percent of your call volume consists of patients with a Medicare product as their primary insurance and another ten percent have Medicaid as primary, that’s 210 claims that paid at an average of $400 per claim.

That equates to a payback of $84,000 multiplied by factor of 3 or $252,000. Now add to that just the minimum civil monetary penalty of $11,803 per claim and the amount of money your ambulance service now must pay to the Federal government just ballooned to nearly $2.5 MILLION!!!

One simple online search could have prevented all of this!!

Time to Run the names, NOW!!!!  AND…establish an ongoing monthly review.

Today is the day to run the LEIE name list!

You can visit https://exclusions.oig.us.gov.

You’ll need your staff members’ and Board members’ proper names and Social Security Numbers to locate if any one person connected to your organization has been placed on the exclusion list.

Run the names of everyone connected to your organization so your EMS organization isn’t the next one in the news!!

If you don’t have this step added to your new hire diligence, now is the time to add it. Then, moving forward a review of the excluded list should occur on a monthly basis and all results must be retained should you ever have to produce the evidence for an auditor.


*Chuck Humphrey is the Senior Director of Compliance and a Territory Sales Manager for Quick Med Claims. He is one of our industry experts with over 30 years of experience in the EMS industry.

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