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Excluded providers falling through the cracks

Posted by Margaret Scavotto, JD, CHC on 6/17/15 7:00 AM

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Under the Affordable Care Act, if a provider is "excluded" from participating in Medicare or Medicaid "for cause," states are required to exclude that provider as well. And yet in many states, excluded parties are falling through the cracks.

A special report by Reuters reveals that 20% of providers excluded from Medicare were still billing State Medicaid programs. For example:

  • A doctor excluded from billing in Georgia continued to bill South Carolina Medicaid for almost a year.
  • A doctor remained eligible to bill Pennsylvania Medicaid despite serving a multi-year prison term for taking illegal payments for hospice referrals.
  • A doctor pleaded no contest to felony workers' compensation fraud in Ohio in 2011, and CMS revoked his billing privileges; Ohio revoked his license to practice medicine in 2012. The doctor continued to bill Illinois Medicaid through April 2013.

While these examples involve physicians, the same delays in updating exclusion status can occur with other providers.

Scenarios like these can sometimes be explained by incomplete data, state and federal databases that don't synchronize, or even differing interpretations of excluded provider requirements. 

Are you doing everything you can to find excluded providers?

Steep penalties apply for providers who submit claims to Medicare or Medicaid for services provided by excluded parties. And there are other reasons why providers want to be sure excluded providers aren't working in their facilities--these providers can pose threats to compliance integrity or, in some cases, to the patients we serve.

With the OIG increasing its use of data mining to locate excluded providers, providers' efforts to screen employees are more important than ever. Are you doing everything you can to find excluded providers?

What you can do

Check for excluded providers before hire/contracting, and monthly.  Partnering with a software vendor is a relatively simple and cost effective alternative to using staff time to perform the same function. If you hire personnel who have previously worked in other states, you might want to consider conducting a screen in those states, too.

If you conduct a screen and find an excluded employee or contractor, contact legal counsel immediately. The OIG reports that self-disclosure and quick action can result in leniency when calculating fines.

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Topics: Excluded Providers

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