Introduction to Sanction Checks

- September 04, 2015 -

As a major part of the credentialing process, all physicians are required to undergo sanction checks before they are granted any staff privileges—think background checks.

Sanction screenings are federally required to maintain quality health care and safety. It is effective for ensuring that facilities do not employ individuals who are unskilled or have been convicted of criminal violations. The information is used by the credential manager when investigating the work and educational history of the physician that they are considering for employment.

These healthcare sanction checks include searching records from the following organizations:

  • Office of Inspector General (OIG)
  • National Practitioner Data Bank (NPDB)
  • Malpractice Insurance Claims History

As a credential manager, it is important to recognize the different sanction checks. In the following sections, we will be giving you some insight on the three sanction checks to help you better understand each type.

Office of Inspector General (OIG)

The OIG is a federal office established under the U.S. Department of Health and Human Resources. It is a Medicare and Medicaid-centered establishment for fighting fraud and waste in health and human resource programs in America.

The OIG maintains a monthly-updated list of all excluded individuals and entities called the List of Excluded Individuals and Entities (LEIE). It is a mandated exclusion from participating in all Federal health care programs for all individuals who are convicted of criminal offenses such as health care fraud, patient abuse, unlawful conduct of controlled substances, and others. The current list can be found on the OIG website. Credential managers need to routinely check the LEIE to ensure that no prospective or current physicians are listed.

Physicians may be appointed or reappointed if they do not show up on the LEIE. If the facility employs a physician who appears on the list, the facility may be subject to Civil Monetary Penalties (CMP), or a fine that imposed by the civil court.

Alternatively, the Provider Self-Disclosure Protocol allows the listed physician to voluntarily disclose self-discovered evidence of fraud to avoid fines and disruptions. However, the listed physicians cannot practice on Medicare patients at all.

Silversheet provides continuous monitoring of OIG to ensure your Doctors are not on the OIG exclusions list.

National Practitioner Data Bank (NPDB)

The National Practitioner Data Bank is a U.S. program created to improve health care quality by reducing health care fraud and abuse. It collects data and maintains reports on medical malpractice, health care convictions, exclusions, and more. The information applies directly to physicians and is queried by medical facilities for credentialing and privileging purposes.

The groups that can take reportable actions to NPDB include entities such as medical malpractice payers, state medical license boards, DEA, OIG, and others. Groups who do not report necessary information may face hefty fines more than $25,000 and loss of protection. Physicians and facilities are not required to report on their own accreditation recommendations.

As part of the sanction screening process, the credential manager must query the NPDB about the physician undergoing the check and use the information to make informed decisions on appointment or reappointment. The query reports must be current within 120 of physician appointment and reappointment and can be done through the NPDB website.

If the credential manager finds red flags through the query, they often give practicing physicians the opportunity to submit explanations for each reported offense. However, the opportunity does not usually extend to doctors with multiple reported offenses.

Malpractice Insurance Claims History

Medical malpractice occurs when a physician or hospital provides negligent services which lead to below standard treatment or worsening of the injury. Medical malpractice insurance companies protect the interests of physicians and surgeons by offering settlement costs and legal defense. An example of a widely-used malpractice insurer is The Doctor’s Company.

When preparing for the accreditation survey, the credential manager must individually query the malpractice insurance carriers in order to determine if there have be previous claims paid or filed against the physician. The credential manager must retrieve the date the claim was received by the physician, the date the claim was resolved with the malpractice insurance company, and an explanation on the claim’s reason and status. Once done, the credentials are sent to the facility’s board for review.

Though querying malpractice insurance companies may be more labor-intensive, credential managers are able to find claims that are not reported in the NPDB due to the NPDB’s reporting regulations. Using the malpractice claims history to verify a physician's liability is highly beneficial for risk-reduction and quality-control for the facility.

Proof of a physician’s medical malpractice history is one of the most important and complicated steps in proper credentialing. When a physician is found to have an unfavorable history, it is the credential manager’s job to follow the correct protocols.

Look out for our credential management course on how to follow the proper protocols for dealing with each type of sanction check!