The Excluded Biller in the Back Office
A home health agency's monthly exclusion screening is run by the billing manager against the OIG LEIE only, using a spreadsheet of employee names and dates of birth. In March, an internal tip alleges that a billing specialist, hired 19 months ago, was excluded in a prior state for a healthcare fraud conviction. The agency confirms the individual appears on the LEIE with an exclusion effective date 22 months ago. The specialist processed claims during the entire 19-month period, and the agency submitted roughly 4,100 Medicare claims in that window, of which the specialist touched an unknown subset. The agency's policy says screening occurs at hire and monthly; the billing manager says she screened at hire and monthly but did not match the middle name.
1. Explain the exposure created by employing an excluded individual and what the agency must do first.
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An excluded person may not furnish, or be involved in furnishing, items or services billed to Medicare. The exposure is not limited to claims the specialist personally touched: the OIG's position is that services furnished by an excluded individual, and services performed by others at the direction of an excluded individual, are not payable. The agency must first remove the individual from any role touching federally funded claims and from patient care, then preserve all records of her activity. Do not terminate in a way that destroys records or appears retaliatory without HR and counsel review. Next, determine the scope: pull audit logs, claim history, and job duties to establish which claims she handled or directed. The agency should expect that a broad reading of "involved in furnishing" could sweep in the full 4,100 claims, so it should quantify both a narrow and a broad exposure before deciding on disclosure. Also correct the screening failure - LEIE-only screening misses SAM exclusions and state Medicaid lists, and name-plus-DOB matching without a secondary identifier is prone to exactly this miss.
2. The agency wants to know whether it can simply repay the subset of claims the specialist personally keyed. Advise.
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That is likely too narrow and would be hard to defend. The relevant question is not who keyed the claim but whether the excluded individual furnished or was involved in furnishing the service, and whether others acted at her direction. A billing specialist who processed claims, applied coding, or resolved edits was involved in furnishing them for payment purposes. A defensible approach: conduct a documented review of her actual duties and system access, define a defensible scope, and if the review shows she materially participated in the billing chain, treat the affected claims as an overpayment, return them, and consider self-disclosure through the OIG's self-disclosure protocol, which can mitigate per-claim civil monetary penalties. Repaying only the keyed subset, without a documented rationale for the narrower scope, invites a later finding that the agency knowingly under-returned. Escalate to counsel before any repayment or disclosure decision, and document the reasoning contemporaneously.