To avoid substantial fines and loss of resources, retail pharmacies must screen for OIG-excluded prescribers before submitting a claim to government prescription plans. The Excluded Prescriber Monitoring Service can help pharmacies comply.

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The Office of Inspector General (OIG) 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 Medicare, Medicaid 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 with OIG-excluded prescriber monitoring

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 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 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 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 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 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