Excluded Prescriber Monitoring Service: OIG Audit Risk Mitigation for Pharmacies

Get real-time prescription claims monitoring for OIG-exclusion list with RelayHealth’s Excluded Prescriber Monitoring Service.

To avoid substantial fines and loss of resources, retail pharmacies must screen for prescribers on OIG's-exclusion list before submitting a claim to government prescription plans. The Excluded Prescriber Monitoring Service can help pharmacies comply with OIG-Exclusion list screening.

 

The Office of Inspector General () works to identify and eliminate fraud, waste, and abuse in federal health care programs. If the OIG determines that your pharmacy or one of its pharmacists has engaged in fraud or abuse, your pharmacy may be excluded from participation in , and other federal health care programs. You may also face fines of $10,000, along with three times the claimed amount for each audited instance.¹

Reduce pharmacy audit risk by monitoring OIG's-exclusion list of prescribers

RelayHealth's Excluded Prescriber Monitoring Service (EPMS) provides real-time claims monitoring to help pharmacists avoid adjudicating government prescription plan claims for prescriptions written by OIG excluded prescribers. Here’s how it works:

  • EPMS maps the RelayHealth knowledge base of known government prescription plans against its proprietary prescriber analytics, as well as the OIG exclusion list.
  • EPMS rejects any OIG excluded provider claim before submission to the payer, preventing an improper reimbursement request.

RelayHealth offers additional audit risk and mitigation services, including services to validate DEA prescriptive authority and other audit-triggering pharmacy claims transactions.

This service aids pharmacy audit risk prevention and cost savings by:

  • Reducing the risk of potential audit fines or loss of Medicare/Medicaid claims-processing privileges
  • Increasing time- and cost-saving opportunities—no integration with the pharmacy management system required
  • Helping you navigate an OIG pharmacy audit with additional support and enhanced reporting

Excluded Provider Monitoring Service features include:

  • Connections to tens of thousands of pharmacies
  • Real-time monitoring for immediate action at the point of dispense
  • System alerts when a prescription claim shows as definitively or potentially federally funded
  • Reports that identify the action taken by pharmacy personnel, as well as payer response if pharmacy personnel override the claims and submit to payer

¹2013 OIG Special Advisory Bulletin: Effect of Exclusion from Participation in Federal Health Care Programs

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