Effective compliance programs must perform background checks and sanctions screening to prevent the employment or credentialing of individuals excluded from participation in federal health care programs. Health care providers are prohibited from billing Medicare, Medicaid and other federal health care programs for services ordered or provided by excluded individuals or companies. Compliance programs must monitor changes in laws and regulations, investigate and respond to identified compliance issues, and return overpayments to federal and state health care programs when errors are identified.
How SoNE HEALTH addresses this standard:
- The Integrity & Compliance Program policy prohibits the employment, credentialing or conducting of business with individuals or entities excluded from participation in federal and state health care programs.
- SoNE HEALTH contracts with third-party companies to perform criminal background checks and federal and state sanctions screening for new colleagues hired in SoNE HEALTH.
- SoNE HEALTH is responsible for screening of medical staff as part of credentialing and re-credentialing processes.
- Federal and state regulators have also established expectations that health care providers continuously monitor monthly updates to federal and state exclusions databases.
- If screening identifies a potential match, actions are taken immediately to confirm the exclusion. If confirmed, individuals and organizations are terminated, suspended from active duty on the medical staff, or removed from SoNE HEALTH supplier systems. Depending on the specific facts and circumstances, additional actions may be required such as notification and repayments to federal health care programs and other third-party payers.