VA Healthcare Purchased from the Community

1. VA HealthcarePurchased from the Community List of Excluded Individuals and Entities (LEIE) Office of Inspector General Chief Business Office Purchased Care Department of Program Integrity (DPI) June 2013

2. Objectives • By the end of this training, attendees should be able to: • Summarize and describe the LEIE • List ways in which the LEIE impacts our VA Mission • Name ways fraud is committed by individuals or entities on the LEIE • Find LEIE information on the internet or the National Non-VA Care Program Office website

3. LEIE • What is the LEIE: • A List of Excluded Individuals and Entities who have been excluded from Federally funded health care programs or other Federal funded programs. • The US Department of Health and Human Services Office of Inspector General (OIG) has the authority to exclude individuals and entities from Federally funded health care programs or other Federal funded programs. (http:exclusions.oig.hhs.gov/)

4. LEIE http://exclusions.oig.hhs.gov/

5. LEIE

6. LEIE • LEIE Authority: • Title XI of Social Security Act 1128, 1156 • 42 U.S.C. 1320a–7a • 42 U.S.C. 1320c5

7. LEIE • Mandatory Exclusions: • OIG required by law to exclude • Hiring of LEIE individuals or entities are subject to civil and monetary penalties • National Non-VA Care Program Offices must check the HHS OIG web site to verify the provider is not on the LEIE: • Prior to entering a new provider in system • Prior to authorization of non-VA services • Prior to payment for non-VA health care claims

8. LEIE • LEIE & Fraud • National Provider Identifier (NPI) is now the unique number used to identify health care providers. In order to practice: • Excluded Providers or entities commit fraud by using: • Provider Group TIN or NPI • Facility TIN or NPI

9. LEIE • LEIE & Fraud (cont’d) • ExcludedProviders or entities will commit health care fraud by using: • A different name (maiden, previous married, hyphenated name) • Their personal Social Security number instead of a TIN or NPI

10. Conclusion • Summarized and described the LEIE • Listed ways in which the LEIE impacts our VA Mission • Named ways fraud is committed by individuals or entities on the LEIE • Identified how to find LEIE information on the internet or the National Non-VA Care Program Office website

11. LEIE • References, Resources and Links: • https://oig.hhs.gov/exclusions/background.asp • http://www.ssa.gov/OP_Home/ssact/title11/1128.htm • http://www.ssa.gov/OP_Home/ssact/title11/1156.htm • https://oig.hhs.gov/fraud/report-fraud/index.asp

12. References Veterans Affairs manages several health care programs that reimburse private health care providers for caring for our Veterans and their eligible family members. Unfortunately, these health care programs have a different statutory and regulatory authority, which creates diverse payment methodologies. The majority of VA health care programs utilize Medicare’s payment methodologies or something very similar. Therefore, providers and facilities that utilize Medicare’s billing and coding guidelines will greatly minimize claim delays or rejections as a result of the Program Integrity Tools’ Improper Payment Review. The following Medicare link is an excellent source of billing and coding guidance for all providers and facilities: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf