What is a Mandatory Exclusion in the Healthcare Industry?
Protecting patients and employees within the healthcare industry is critical for leaders and healthcare HR professionals. The Office of Inspector General (OIG) must, by law, ensure that individuals and entities who have committed fraud, waste, or abuse can no longer participate in federal healthcare programs, like Medicare or Medicaid. In this blog, we explore what a mandatory exclusion is and the impact it can have on a healthcare organization or individual. We’ll also share some key ways you can work to avoid issues with mandatory exclusion through regular audits and compliance checks. Definition of Mandatory Exclusion Mandatory exclusion is a legal requirement to exclude participation in federal healthcare programs following an individual or entity’s conviction for various criminal offenses. Common reasons for being included on the list include Medicaid or Medicare fraud; fraud related to the State Children’s Health Insurance Program (CHIP), Tricare, or other state programs; patient abuse or neglect; felony convictions for fraud, theft, or other financial misconduct; and felony convictions involving the unlawful manufacture, distribution, prescription, or dispensing of controlled substances. Those organizations or individuals who find themselves on this list cannot receive payment from federal healthcare programs. Keep in mind that you’ll also find permissive exclusions on the list. These exclusions may result from misdemeanor convictions related to healthcare fraud, fraud in a program other than a healthcare program, misdemeanor convictions for the unlawful manufacture, distribution, prescription, or dispensing of controlled substances, or the suspension, revocation, or surrender of a healthcare license due to issues of competence. The term of exclusion usually sits in the one to three-year range for these types of exclusions, compared to five years to indefinite exclusion with mandatory exclusions. Common Contexts for Mandatory Exclusions Mandatory exclusions impact the individual or organization on the list and can put your organization at risk. This impact is why organizations must check the list monthly to avoid finding themselves in legal trouble or at risk for non-reimbursement due to having someone on the exclusions list perform services on behalf of their organization. Exclusions apply to all employees, whether licensed or not, as well as contractors, vendors, and referring physicians. Many state Medicaid bulletins suggest monthly monitoring of ordering and referring physicians, underscoring the importance of regular checks to ensure compliance. Consequences of Mandatory Exclusion You’ll find immediate and long-term consequences if your organization or an individual working within your organization finds themselves on the list. Mandatory exclusion usually results in a minimum of five years on the list, but this can be indefinite depending on the severity of the crime or issue that got you on the list. Professional licenses, certifications, and employment will likely be revoked, leaving you with little choice but to find another type of employment. Your reputation within the healthcare industry will be damaged because of this exclusion, and you’ll find that financial penalties can be imposed on you during the exclusion process. In order to get yourself off the list can be a very long and costly process, with many individuals and organizations finding it impossible to remove themselves from the list following their addition. For employers, the impacts are equally significant. Federal health care programs will not make payments for any items or services furnished, ordered, or prescribed by an excluded individual or entity. The payment prohibition extends to the excluded individual or entity, anyone employing or contracting with the excluded party, and any hospital or other provider for which the excluded party performs services. While there is a limited exception for certain emergency items or services not provided in a hospital emergency room, the broader implications of exclusion pose significant operational and financial risks for employers. Avoiding Mandatory Exclusions To avoid mandatory exclusion, ensure that you always follow the best practices set by the industry and the regulations surrounding state healthcare programs. Compliance checks and regular audits can help you avoid getting on the list yourself and stop you from engaging with anyone on the mandatory exclusion list. Should you find out that someone you employ or work with is on the list, it’s critical that you immediately take action to stop your involvement with them. The list is updated each month, usually in the second week of the month. It’s important that your team gets into the habit of regularly auditing the list and your employees so that you can take action should someone appear on the list. When hiring a company or working with a new employee, review the list before offering them employment or setting up business contracts. These steps protect your organization and its reputation and will help you avoid ending up on the list yourself for fraud or other illegal activities. Conclusion | About Propelus Understanding and avoiding mandatory exclusions is critical for anyone operating a business within the healthcare industry. Propelus can support your efforts. We recently announced the launch of our Exclusions Monitoring API, which provides monthly monitoring of healthcare exclusions and ensures exclusions intelligence is accessible how, when, and where it is needed for more informed, real-time compliance with ease. Additionally, our EverCheck by Propelus solution delivers the most up-to-date primary source data, including exclusions monitoring, so you can have confidence that your workforce is compliant and in good standing. By remaining in compliance, you’ll work to protect your reputation, avoid potential loss of trust, and ensure you also don’t end up on the list in the future.
Propelus Honored as Silver Stevie® Award Winner In 2024 Stevie Awards For Technology Excellence
Jacksonville, FL – August 21, 2024 -Propelus has been named the winner of a Silver Stevie® Award in the Technical Innovation of the Year – Business Technology category in the first annual Stevie Awards for Technology Excellence, “the Olympics for technology.” The Stevie Awards for Technology Excellence celebrate the remarkable accomplishments of individuals, teams, and organizations shaping the future of technology across all industry sectors. Winners of the awards, named the Stevies from the Greek word meaning “crowned,” will be recognized during a gala awards dinner on Monday, September 16 at the Marriott Marquis Hotel in New York City. More than 600 nominations from organizations of all sizes in 21 nations and territories were submitted this year for consideration in a wide range of tech-related categories, including Company of the Year, Educational or Research Institution of the Year, Technical Innovation of the Year, Technology Breakthrough of the Year, and more in a variety of industry groupings including Advertising, Marketing, and PR, Aerospace Technology, Biotechnology, Business Technology, Healthcare Technology, among others. Propelus is a winner in the Technical Innovation of the Year – Business Technology category for the computer software industry. Propelus’ winning nomination for Primary Source Verification (PSV) API has been honored with a Silver Stevie® Award in the Technical Innovation of the Year category. This award recognizes our commitment to transforming the healthcare compliance landscape through innovative technology. The Propelus PSV API automates the time-intensive and error-prone process of verifying licenses and primary source data, ensuring that healthcare organizations can manage credentials with unparalleled efficiency and compliance. Judges praised our submission, noting that the PSV API “automates primary source verification for healthcare organizations, ensuring active, compliant credentials with real-time monitoring and integration into HR systems.” They highlighted the innovative nature of the API, stating that it “impressively automates a traditionally manual process, enhancing compliance and operational efficiency.” “This award reflects the hard work and dedication of our team in developing solutions that not only meet industry needs but also set a new standard for healthcare compliance. We are proud that our modern API is secure and built for enterprise scale. It can verify millions of licenses a day which seamlessly ensures safer and more efficient healthcare operations.” – John Barnes, Chief Product and Technology Officer at Propelus. The Silver Stevie® Award reinforces Propelus’s commitment to innovation and excellence in the healthcare sector, and we look forward to continuing to enhance workforce compliance through our groundbreaking solutions. More than 100 professionals worldwide participated in the judging process to select this year’s honorees. “We congratulate all of the winners in the inaugural edition of the Stevie Awards for Technology Excellence for their outstanding performance, and we look forward to celebrating their achievements on September 16,” said Stevies president Maggie Miller. Details about the Stevie Awards for Technology Excellence and the list of 2024 Stevie winners are available at www.StevieAwards.com/Tech. About Propelus As a leader in dynamic workforce compliance technology, Propelus is modernizing how healthcare professionals and the broader healthcare ecosystem– employers, providers, payers, regulators, and partners–work better together. For over 20 years, Propelus solutions have propelled millions of professionals by providing market-leading technology, essential connectivity, data & insights, and unparalleled strategic partnerships. We power critical integrated governance, risk management, and compliance (iGRC) for a happier workforce, better operations, and safer communities. Learn why Propelus is trusted by 5+ million professionals: https://propelus.com/. About the Stevie Awards Stevie Awards are conferred in nine programs: the Asia-Pacific Stevie Awards, the German Stevie Awards, the Middle East & North Africa Stevie Awards, The American Business Awards®, The International Business Awards®, the Stevie Awards for Great Employers, the Stevie Awards for Women in Business, the Stevie Awards for Technology Excellence and the Stevie Awards for Sales & Customer Service. Stevie Awards competitions receive more than 12,000 entries each year from organizations in more than 70 nations and territories. Honoring organizations of all types and sizes and the people behind them, the Stevies recognize outstanding performances in the workplace worldwide. Learn more about the Stevie Awards at http://www.StevieAwards.com.