For many years, the United States government has worked diligently to protect individuals such as the elderly and those seeking patient care. The ultimate objective is to clean-up the healthcare system by identifying and eliminating fraud, waste and abuse, and providing a mechanism for audits, inspections and investigations. To that end, specific government departments and programs were born as a checks-and-balances system.

One of the primary goals of the Department of Health and Human Services, in conjunction with the Office of Inspector General (OIG) and the General Services Administration (GSA), was to create and maintain a sanction list of individuals and entities called the “List of Excluded Individuals/Entities.” OIG/GSA 101: These databases, the “sanction lists,” include individuals and businesses/entities that are excluded from participating in Medicare, Medicaid, or other federally funded healthcare programs, and have been convicted for program related fraud, patient abuse, licensing board sanctions, suspended licenses, and default on Health Education Assistance Loans. To net it out, a healthcare organization cannot do business, or be associated with, anyone or any business on these sanction lists.

For Healthcare organizations, being in federal compliance is vital, and searches on the OIG and GSA databases is mandated on a pre-employment and annual basis for every individual or entity within, or tied to, the organization. In other words, anyone working within the walls of a healthcare organization, be it employee, service firm or contractor, must be checked. If an organization has an affiliation with an individual or entity included on one of the sanction lists, they may be forced to pay back all Federal funds back to the date the individual or entity became affiliated with the organization. This could mean hundreds of thousands in lost revenue depending on the length of the violation. In addition, Civil Monetary Penalties (CMPs) of up to $10,000 per violation can also be levied. Continued violations could even mean that a healthcare organization be denied to receive any government funds from Medicare, Medicaid or any other government supplemented program, virtual putting them out of business.

The question is will OIG and GSA searches alone ensure complete compliance? The answer is two-fold: “yes” on a federal level, but “no” on a state level.

The OIG and GSA federal databases only reflect the current status of an individual or entity and provide no historical data. If there was fraudulent or criminal activity in the past with an individual or business, and the healthcare organization continued the relationship, the organization would be in jeopardy for liable and non-compliance. On a state level, most states maintain their own database with state specific sanction information that may not be updated into the OIG and GSA. These state exclusion and sanction lists pertain to state fraud, along with medical license information which may reflect a suspended or revoked license.

The only way to ensure proper compliance is to include a multi-state search, in addition to the OIG and GSA searches. Global screening firms, such as Employment Background Investigations, can provide multi-level options of screening against a comprehensive and historical database of adverse actions and sanctions, and provide batch processing and yearly program management. Enhanced due diligence and risk mitigation can only be achieved by a thorough search of both federal and multiple state databases.