The OIG check, sanction checks, and the Open Payments CMS are among the most crucial tools and processes for ensuring healthcare integrity. All these repeat several times. And are an answer with the uses of these systems as a way to ensure transparency. And helps to prevent frauds. The definition of an OIG check is an act to verify whether an individual or entity appears on the Office of Inspector General's (OIG) Exclusion List. 

Why are OIG checks important?

Healthcare providers must conduct OIG checks to avoid employing or contracting with individuals whose names appear on the exclusion list. In case you hire or associate with an excluded individual, it may lead to the worst consequences. Including financial penalties, loss of reimbursement, and even some legal activities. Regular OIG checks can help avoid these and keep the healthcare organization in line with federal laws. Regarding eligibility, individuals and entities engaged in federally funded programs.

Who Ends Up on the OIG Exclusion List?

The OIG puts individuals and businesses on the exclusion list due to fraud or abuse in Medicare, Medicaid, or any other federal healthcare program. And finally, criminal offenses during the delivery of healthcare. 

For example, a provider who has been convicted of patient abuse or healthcare fraud is mandatorily excluded. While those who have been convicted of relatively minor offenses are permitted to be excluded.

Sanction Check and Its Importance

The scope of sanction checks is broader compared to OIG checks. That is imposed by regulatory bodies, federal or state departments, or licensing commissions. Usually, sanction checks are very important. They check if the health care providers adhere to the different regulations that govern them. 

Why Perform Sanction Check?

Sanction checks are part of any compliance program for a health organization. Because they ensure health practitioners, providers, and vendors adhere to the requirements given by both federal and state regulations. Sanction checks thereby help steer clear of penalties and reputational damage.

The healthcare organizations will systematically check their sanctions to identify the sanctioned or excluded individual or entity. Due to unethical practices and the violation of some laws or professional misconduct. This would reduce risks such as non-compliance against the regulatory authorities. And make the organization remain in good standing with them. 

Types of sanctions and the agencies involved

Sanction checks include many sanctions issued by various authorities. Some common sanction sources are: 

OIG Exclusions: The OIG includes the names and other details of prohibited organizations, individuals or entities. 

General Services Administration (GSA): SAM, or System for Award Management, lists individuals and entities who are prohibited from receiving federal contracts or grants.

Department of Health and Human Services (HHS): HHS can inflict a huge amount of penalties and other sanctions if providers violate the healthcare laws.

Comprehensive sanction checks are maintained by health care organizations. That enables them to not be in violation of any law.

Open Payments CMS: The System for Improving Transparency in Healthcare

Also known as the Sunshine Act. The CMS program contains information about payments and transfers of value between physicians and teaching hospitals. The Open Payments CMS database will now bring such information to the public domain. The sum of financial relationships between manufacturers and providers into the public domain. Its purpose is to clarify potential conflicts of interest in healthcare. So patients and regulators are made aware of the relationships. 

What Does the Open Payments CMS Track?

The Open Payments CMS keeps track of these types of financial interactions between manufacturers and healthcare providers.

Payments: Any kind of money payment, gift, or compensation to a healthcare provider.

Ownership Interests: That a provider has in a company owned by the manufacturer.

Investment Interests: ownership stakes the providers have with manufacturers of drugs or medical devices. It is publicly accessible through the Open Payments CMS website and updated every year. 

Best Practices for Healthcare Compliance

Healthcare organizations shall ensure compliance with the relevant regulations. By following best practices in relation to OIG checks, sanction checks, and monitoring of disclosures under Open Payments CMS. 

Routine Screening: This includes OIG checks and sanction checks on all staff, vendors, and contractors in a routine manner. This is also encompassed within testing at the time of employment. And further tests at routine intervals while working.

Comprehensive Reporting: All financial interests must be reported totally. And rightfully as per the requirements laid down by Open Payments CMS. 

Clear policies and procedures: It details the specific steps of checking OIG checks, sanction checks, and maintenance of Open Payments CMS. Training and education of applicable staff on these procedures will be performed. 

Adoption of Technology: Implement the use of technology to automate checks for OIG and sanction checks. There are many software tools designed to organize the process of cross-checking individuals and entities against exclusion and sanction lists. 

Maintain Detailed Records: Keep detailed records of the OIG checks, sanctions checks, and financial disclosure reports submitted to the Open Payments CMS repository. This may come in handy as evidence in the case of an audit that it has indeed been done. 

Healthcare compliance ensures a qualified and ethical professional is providing services to patients. Healthcare organizations can avoid fraud and legal consequences and win patients' trust. If they conduct checks for OIG, sanction checks, and explain themselves through the Open Payments CMS program.