What are a Health Care Provider's Participation Review Obligations When Employing and/or Contracting with Individuals and Entities?
Health care providers participating in governmental health care programs, including Medicare and Medicaid, must ensure that their employees, physicians, vendors and other associated parties are not excluded, debarred or suspended from participation in any governmental health care programs. Exclusion, debarment and/or suspension of an individual or entity can result for a numbers of reasons, including fraudulent and/or abuse conduct, compliance issues and quality control breaches and health care providers must conduct comprehensive cross-checks and reviews to ensure an individual or entities eligibility to participate.
The result of exclusion, debarment and/or suspension is that health care providers may not bill any federal health care program for services provided by an excluded individual or entity and civil monetary penalties may be imposed against health care providers that employ or enter into contracts with excluded individuals or entities to provide items of service. In fact, the law prohibits both direct and indirect payments to excluded individuals or entities, including the payment of salaries or wages.
Both the federal and state governments use exclusion as an enforcement tool. In the State of New York, for example, the Office of Medicaid Inspector General mandates that health care providers cannot submit claims or accept payment for medical care, services or supplies furnished by a person excluded from participation in the Medicaid program or furnished in violation of any condition of the Medicaid program. Further, any party excluded from the Medicaid program cannot be involved in any activity relating to the furnishing of medical care, services or supplies for which claims are submitted to the Medicaid program.
Providers participating in governmental health care programs can find a comprehensive compliance tool at Health Care Compliance Watch for ensuring that physicians, employees and vendors are and remain eligible for program participation.
For more information concerning your obligations and exposure when employing and/or contracting with individuals and entities, please contact Ms. Ilana Sable, Esq.
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