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Patient and Employee Screening in Your Medical Office to Avoid CMPs

Medical office empoyee who has passed all employee screenings.The OIG (Office of the Inspector General) is cracking down more than ever in 2015 on Medicare fraud and abuse, which means that it’s a crucial time to review your medical office’s patient and employee screening practices. Recent statutes have expanded the authority of the OIG to exclude individuals from all federal health care programs. Part of HIPAA compliance means understanding how to engage, employ or contract with excluded individuals.

Those persons or programs that have been found guilty of misconduct according to federal regulation will face CMPs (civil monetary penalties). To avoid those steep fines and penalties, it’s best to remember the following:

  1. The Reason for Exclusions – By understanding the exclusions and knowing your employee or patient history (i.e. patient and employee screening), it’s easier to correctly identify those who are excluded from federal health care programs including Medicare and Medicaid. So just who are excluded?
    • Physicians and practitioners convicted of program-related crimes.
    • Individuals convicted of previous health care fraud.
  2. The Effect of Exclusions – Simply put, an exclusion means that no federal program payment will be made for items or services furnished or prescribed by an excluded individual. Reimbursement will not be given, no matter if the payment results from fee schedules, cost reports, itemized claims or PPS (prospective payment system). Even if a federal payment is made to another provider, supplier, or practitioner, the prohibition still applies. So if your establishment fails to engage in proper patient and employee screening, you are jeopardizing yourself to federal misconduct.
  3. Common Misconceptions – Many healthcare providers have suffered CMPs, not from a lack of patient or employee screening, but rather from a lack of up-to-date information regarding exceptions. Some common misconceptions include:
    • Administrative and management services not directly related to patient care are not affected. ->Truth: All parts of the process can be audited and lead to CMPs.
    • An excluded person is no longer excluded if he or she changes health care professions. ->Truth: Excluded persons remain prohibited from participating, no matter his or her current profession.

When audits, inspections, and investigations come around, you want to have your hypothetical ducks in a row by following all the necessary regulations. Patient and employee screening in your medical office is one of the highest priorities to ensure security and detect abuse on Medicare and health insurance. After all, your clinic is liable and could face serious CMPs ($10,000 per item or service).

While you are revisiting your patient and employee screening process, consider outsourcing the billing of your practice to Billing Advantage. Billing Advantage ensures proper handling of client information and fast results. Thus, your practice can have peace of mind while maximizing reimbursement.


Donna Whipple Donna Whipple

Donna Whipple, Psy.D. is a clinical psychologist with over 30 years of management experience. She has particular interest and expertise in HIPAA and ethical treatment and business practices in a changing high tech industry. She has a particular talent in boiling down complex regulations so providers can understand and comply with them. As co-owner of Billing Advantage Inc., Donna is involved in all aspects of the company but her particular contributions to the business is in mentoring upper level managers and helping them be more effective in their leadership.


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