Medical care is necessary to prevent diseases and improve quality of life. With many doctors...
In July 2017, the federal OIG exclusions list contained almost 68,000 individuals and entities who are excluded from federal reimbursement for goods and services. State sanctions lists often have more - some providers on state lists are not included on the federal lists.
If you work with Medicare/Medicaid, you will only receive reimbursement for legitimate services - i.e. NOT services provided by excluded entities. If you knowingly or unknowingly make a claim for services from an excluded provider, your clinic will face compliance issues and fines.
These goods and services include:
Exclusion lists are lists of people or entities who have been officially excluded or sanctioned from providing healthcare services.
The full OIG exclusion list is called the List of Excluded Persons or Entities - this list applies to all healthcare services, and is maintained by the OIG. There are multiple databases for federal and state Medicaid exclusion lists. Excluded providers can be found on either federal or state lists.
There are other lists and regulations that only apply in certain situations:
You can view the Texas Exclusions Database here and the Federal Exclusions Database here.
For a provider to be on the OIG exclusion list, they will have committed Mandatory or Permissive breaches:
Mandatory exclusions last for 5 years, but can be indefinite depending on the circumstances. Permissive exclusions last UP TO 5 years, but typically only last 1-3 years.
Once the exclusion period is up, providers must apply for reinstatement at the federal and state level. Reinstatement is not automatic.
Consequences will depend on whether you’ve been reimbursed through Medicare or Medicaid.
Based on the Civil Monetary Penalty (CMP) law, you will be fined if you receive reimbursement by an excluded provider.
While this law does require screening exclusion lists each month, you WILL be subjected to fines if you discover you have hired, contracted, or accepted a referral from an excluded provider. If you discover you’ve worked with an excluded provider, you should report them to the OIG via the provider self-disclosure protocol.
The CMS State Operations Manual requires you to screen on a monthly basis. (Some states will also have separate state laws or regulations requiring this.)
If you receive reimbursement for improper services, you must refund that money to Medicare/Medicaid within 60 days of discovery (starting when the services became improper).
It is HIGHLY recommended that you run sanctions monthly to prevent major compliance issues and fines. While unlikely, excluded providers do slip through the cracks. Handing over a month’s worth of Medicare/Medicaid funds is much more manageable than a year’s worth.
Not sure if all of your providers are compliant, or how to start auditing? Contact us for direct assistance.
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