The Office of Inspector General (OIG) is tasked with identifying and eliminating fraud, waste, and abuse in federal health care programs. If the OIG deems an individual or entity has engaged in fraud or abuse, the OIG may exclude them from participation in Medicare, Medicaid and other federal health care programs - and potentially impose financial penalties. If a prescription claim from an excluded party is paid by a federal program, it may result in fines of $10,000, plus three times the claimed amount per audited instance.¹ It's important for retail pharmacies to screen for OIG excluded prescribers before submitting a claim to government prescription plans.


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Reduce pharmacy audit risk with OIG excluded prescribers monitoring

RelayHealth's Excluded Prescriber Monitoring Service (EPMS) provides real-time monitoring of claims so that a pharmacist may avoid adjudicating government prescription plan claims for prescriptions written by excluded prescribers. EPMS maps our knowledge base of known government prescription plans with our proprietary prescriber analytics and the OIG exclusion list. With this mapping EPMS will reject the claim before submission to the payer, helping the pharmacy avoid an improper reimbursement request. RelayHealth offers a host of other audit risk and mitigation services including services to validate DEA prescriptive authority and other audit-triggering pharmacy claims transactions.

Features of Excluded Provider Monitoring Service:
  • Leverages the intelligent network and connections to tens of thousands of pharmacies
  • Real-time monitoring enables immediate action at the point of dispense
  • System alerts user when the claim is definitively or potentially a federally-funded claim
  • Reports identify the action taken by pharmacy personnel and the payer response if pharmacy personnel overrides the claims and submits to the payer
EPMS can help:
  • Reduce the risk of potential audit fines or loss of Medicare/Medicaid claims processing privileges
  • Increase the opportunity to save time and money—no integration with the pharmacy management system is necessary
  • Provide additional support in the event of an OIG audit with enhanced reporting

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