Physician Background Check: Navigating OIG Guidelines for Screening

With the Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and state Medicaid AgenciesThe Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and state Medicaid Agencies all call for more frequent sanction screening. But how can your organization effectively screen physicians without wasting resources – or creating an extra lift for your compliance team? 

This article explores how following best practices enables full compliance while managing costs. We will analyse the most common challenges screening presents for healthcare organizations, along with the benefits of regular, robust screening. 

Why Physician Background Checks Are Essential for Healthcare Compliance 

The OIG has excluded over 17,000 physicians since 2013, making the chances you might unknowingly hire an excluded individual surprisingly high. Sanction screening provides a vital protection against that possibility and should be a core part of any physician background check.  It allows you to: 

• Protect Patients: Many physicians are included on exclusion lists due to a history of patient neglect or abuse. Sanction screening helps you identify such individuals and ensure your patients are not put at risk. 
• Avoid Fines: Employing an excluded physician can lead to heavy fines, with several recent high-profile cases leading to 6-figure penalties from the OIG. 
• Safeguard Funding: Hiring excluded physicians can lead to exclusion from Medicare reimbursements and lost funding, with serious negative implications for your organization’s finances. 

Challenges in Conducting Physician Sanction Checks 

It can be difficult to identify whether a physician actually requires a thorough background check. There may be thousands of different physicians referring a patient to a hospital with which the physician has no personal contact. The cost of screening each of these physicians and resolving potential hits can be an expensive proposition. 

Often, a physician who refers a patient to a hospital may not be from the area, be personally unknown, or have never referred a patient to that hospital before and may not do so again. Retired persons living in a location separate from their original area of residency or home are commonly referred by a local physician to a home area hospital. 

It is unreasonable for the hospital receiving a patient referred by a physician to screen the referring physician in advance of providing a service. In many cases, the hospital will not have any identifiable data on that physician. 

If a referring physician is found to be a positive match against the OIG’s List of Excluded Individuals and Entities, there is little the hospital can do about it other than request that the physician not refer any more patients. 

These issues may be further exacerbated by: 

• Exclusion List Volume: Healthcare compliance teams must scan multiple exclusions lists – including the OIG’s exclusions lists and the SAM, along with any relevant state-level list. This creates a large volume of effort, especially if your team is running checks manually. 
• Verification Processes: False positives are a common problem with sanction screening, as many physicians have relatively common names. Their name may therefore be listed on an exclusion list – but it is actually another person. As a result, verification processes are required to avoid penalising innocent physicians, which adds to the screening workload. 
• Unnecessary Screening: Some organizations may end up screening individuals and entities unnecessarily or too frequently, which can become counterproductive and quickly drain the organization’s resources and budget. For example, an organization may be screening physicians who are not on staff or have staff privileges at a hospital; however, neither CMS nor the OIG call for such screenings. 

The net result is that screening processes must be highly efficient and scalable to ensure full compliance without draining resources.  

Best Practices for Sanction Screening Physicians 

Our experience working with hospitals and other healthcare organizations suggests four steps can make physician background checks far more effective and efficient: 

1. Regular Screening Intervals 

Conducting regular sanction screenings helps ensure that new sanctions against healthcare professionals are identified promptly. Regular intervals, such as monthly screenings, mitigate risks by reducing the window of time a sanctioned physician might practice in violation of regulations. This proactive approach enhances compliance with legal mandates and protects against potential penalties or legal actions. 

2. Comprehensive Database Use 

Utilizing a comprehensive database, which includes federal, state, and local sanction lists, ensures a thorough verification process. This is critical because sanctions can occur at various government levels, and missing even one sanction could lead to employing an excluded person, risking fines and reputational damage. A broad search across multiple databases provides a more complete picture of a physician’s standing. 

3. Clear Documentation and Reporting 

Maintaining clear documentation and reporting of sanction screenings is essential for transparency and accountability. Documentation provides proof that due diligence was performed, which is crucial during audits or investigations. Proper record-keeping can demonstrate compliance efforts and help resolve potential disputes with regulatory bodies more effectively. 

4. Automated Screening Processes 

Leverage software that can run regular exclusion list checks and verify results to scan more physicians faster – and save your compliance team a lot of time. It ensured your screening covers all relevant exclusion lists and can be run at more frequent intervals across a wide range of physicians. 

Enhance Physician Background Checks with Compliance Resource Center 

Implementing these practices can significantly enhance compliance efforts and protect healthcare organizations from legal, financial, and reputational damage. But most organizations will need support to implement them – which is why Compliance Resource Center exists. 

We deliver best-in-class sanction screening software and services to make physician background checks seamless, allowing you to protect your patients and reputation while reducing the resource burden. 

Interested in learning more about sanction screening? Contact Shelby Cole at [email protected]. 

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