NEW Fraud, Waste & Abuse changes could cost you Medicare reimbursements!

Could one of your employees cost you all your Medicare reimbursements? As of September 1st, new Fraud, Waste & Abuse changes say ... YES!

One of the biggest changes to the Fraud, Waste & Abuse regulations involve the OIG Exclusion Verification process. Earlier this year, the OIG process was simple and not too time consuming. Once a year, each pharmacy simply had to submit their employees to the OIG Exclusion database to confirm that no one showed up on the OIG Exclusion list. You printed a sheet for each employee showing that they had passed, stored the documentation in a safe, accessible place and you were done until the next year. Didn’t take too much time and the process was pretty straight forward for pharmacy owners. But now, the rules have changed and what was once easy has become laborious and a bit of an overkill.

When did Fraud, Waste & Abuse changes take place?

As of September 1, 2013, every pharmacy must check their employees monthly against the OIG Exclusion list. Unfortunately, the U.S. Department of Health & Human Services and the Office of Inspector General haven't made this process easy. You can only submit up to five entries at a time on the OIG website. Plus, if you have an employee that has used different variations of their name, you need to check for all versions. Doing this process every month might make you want to avoid the process entirely and risk the chance of getting caught...except this year is proving to be a doozy with the Government's and the Office of Inspector General's strong crackdown on HIPAA compliance and FWA abuse. If having more enforcement on the loose doesn’t convince you enough to follow the rules, now the price for not checking your employees against the OIG Exclusion list could cost you all your Medicare Part D reimbursements!

How could this happen?

Any employee that is found on the OIG Exclusion list and continues to offer, sell or prescribe any Medicare Part D medication, according to the regulation, can cause all reimbursements connected to those patients to be reinvoked. This means the Office of Inspector General has the right to request all reimbursement money you received, back and for as long as that employee was on the OIG Exclusion list. To put it in perceptive, on average in the United States, a Medicare prescription is filled for a patient every 5 minutes! How many Medicare patients does your business serve and how much money would that cost you? 

What is the OIG Exclusion list?

According to the Office of Inspector General’s site:
"OIG’s List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs.” The most common reasons people get on the OIG Exclusion list is for Medicare or Medicaid fraud, patient abuse or neglect, or any felony convictions for health-care related fraud, theft, or other financial misconduct. 

What happens if my employee is on the OIG Exclusion list?

You must terminate your employee immediately. If you find your employee is on the exclusion list and you do not act, you run a very serious risk of losing all reimbursements for every Medicare Part D customer that employee has served.

How do I check if my employees are on the OIG Exclusion list?

There are two ways. If you are an R.J. Hedges & Associates FWA client, log into the Compliance Portal, click on the "OIG & GSA Exclusion Program" button, and click the "Print" link. Your project manager has already submitted all your employees to the database so all you have to do each month is click the "Print" link, print and keep the documents in your binder. The process is done in just about 20 seconds.

If you are not an R.J. Hedges client, the process is like we said implied earlier...tedious, but still doable. Go to http://exclusions.oig.hhs.gov and click “Search for Multiple Individuals.” Here you can type in up to five individuals. Don’t forget if you have an employee that has used multiple names in the past, such as those with new surnames, you’ll need to search those variations as well.

How often do I need to check the OIG Exclusion list?

Monthly! The good news is that it does not have to happen every 30 days, just every month, meaning you could do it on October 31st and then again November 1st.

If you have more questions on these new Fraud, Waste & Abuse changes, please post below. If you interested in signing up for our FWA program and would like to cut your OIG Verification process time from hours to seconds each month, please check out our FWA Prevention Program or give us as at (724) 357-8380.