Understanding Healthcare Exclusions

Understanding Healthcare Exclusions

Unless you’ve worked closely with healthcare compliance administrators, you may be unfamiliar with the topic of healthcare exclusions. Never fear! Here is everything you need to know about healthcare exclusions.

Defining Healthcare Exclusions for Vendors

An exclusion is an administrative action taken against a person or business by the Dept. of Health and Human Services (HHS), Office of Inspector General (OIG) or a State Medicaid Agency. An exclusion means that person or business is excluded from receiving any money from federal or state healthcare programs. Since healthcare organizations receive federal reimbursement, not working with excluded people or businesses is a way to reduce risk and protect the integrity of taxpayer-funded healthcare.

Whether an excluded person or business is delivering therapy services or preparing food, they are not eligible to work with healthcare organizations that receive reimbursement from Medicare or Medicaid programs.

How Does a Vendor Become Excluded?

An exclusion can be issued for a variety of reasons, but the biggest cause of exclusions among vendors is fraud. Other crimes resulting in exclusions are theft, patient abuse and neglect, and kickback schemes.

Examples of Vendor Fraud:

This Texas-based lab company was prosecuted was prosecuted for fraudulently billing Medicare for travel that never happened. 

These ambulette company owners plead guilty plead guilty to an $8 million kickback scheme.

Exclusion Lists

An exclusion list is one of 43 state and 2 federally maintained lists of individuals and entities who are ineligible to receive any money (directly or indirectly) from federal healthcare programs. Federal and state exclusion lists combined contain more than 200,000 individuals and entities. 

Each one of these lists is a little different from the others. They’re updated at different intervals, they contain different kinds of information and details, and they have different processes for accessing the lists. Checking each list at least once a month (as is required) becomes very tedious. This is one reason why healthcare organizations rely on a solution like VendorProof to conduct their exclusion screening and ongoing monitoring. 

How To Identify Exclusions: Exclusion Monitoring

So there are 45 total lists of excluded individuals and entities and healthcare organizations need to know immediately if someone they employ or partner with appears on any list at any time. The process of comparing a set of individuals or entities to the lists of exclusions is called exclusion monitoring. VendorProof watches the exclusion data and if it finds a match between a healthcare organization’s vendor and an exclusion, it alerts someone at the organization so they can follow the proper procedure. 

When you enroll in VendorProof, you agree to the required exclusion monitoring of your business and ownership information. 

Questions? Reach out to our Vendor Care team. We’re here to help!