For this lesson, we will provide an overview of monitor alerts that you may review. The types of alerts you receive will depend on the services contracted by your organization. There may be additional alerts not covered in this training. Please contact the Client Care support team with any specific questions you may have on your alerts.
For more information on additional level of monitoring services, please reach out to firstname.lastname@example.org or 615-938-7878 ext 1 and we can connect you with the business development team.
There are numerous reasons an individual or entity could be excluded. Federal and state agencies sanction, suspend, exclude or debar individuals and companies from federally funded benefit programs for a variety of reasons, including fraud, drug abuse, issues with licensure, healthcare related misdemeanors or felonies and defaulting on federally backed student loans. Forty-three states, along with the two federal government agencies, maintain exclusion lists that are updated on a regular basis.
If a person or entity is excluded, they cannot receive direct or indirect payment from federal benefit programs. Healthcare organizations cannot make payments to such vendor or person, without incurring a fine or penalty.A complete list of all exclusion sources can be found here. For more information on exclusions, please refer to the educational resources on the ProviderTrust website including E-Books, Blog Posts, Webinars, and Case Studies.
There are two types of Exclusion Alerts for your review in Passport. Matched Exclusion (Red Result Status) and Unable to Determine Exclusion (Yellow Result Status).
MatchedExclusion(Red Result Status) means that we definitively matched your provider to an exclusion on a federal or state exclusion list. When we uncover these, Client Care both calls and emails your organization's designated parties due to time sensitivity.
Unable to Determine Exclusion(Yellow Result Status)means we have found an exclusion with the same name as your provider, however, we do not have enough information from the exclusion source to provide a definitive match or no match verification result. These are most common with older exclusion records and providers who have common names (think - John Anderson, Marcia Garcia, etc). Our verifiers perform advanced research in efforts to reach a definitive result such as using public records data, NPI information, working with credit bureau partners, address history, etc, and have not been able to reach a definitive result with the information available. As we do not believe these can be solved, there is no expectation for you to complete the research where we left off, simply to have a compliance plan in place to address the risk. A best practice among clients is having the provider sign an affidavit stating they have never been excluded and then keeping a record of the signed affidavit. For more information on an unable to determine exclusion and a copy of a sample affidavit, please visit What is An Unable to Determine Exclusion?
If your organization only has exclusion monitoring services, you can continue onto the next lesson on Reports here.
Sanction monitoring searches over 2500 state and federal healthcare mass disciplinary action boards. A sanction represents a disciplinary action, board order, meeting minutes, found against credentialed employees. These can greatly range in severity from a minor fine or complaint to more serious issues related to patient abuse or license revocation. Most sanction alerts will arrive as a Yellow Result Status but those with more severe subjects will receive an elevated Red Result Status. Specifically, any sanction that mentions the words "revoked" or "abuse" will have a Red Result Status.
A sanction does not carry the same severity as an exclusion but can often serve as a precursor to more severe compliance issues such as license revocation or an exclusion.