Exclusion Screening Required in United States Territories

Our experts at Exclusion Screening, LLC maintain fact sheets that contain the screening requirements for providers in every state, including those states that do not currently maintain a separate excluded or terminated provider list. However, Medicaid participation and adherence to exclusion screening requirements does not stop with the fifty states. United States territories like Puerto Rico and the U.S. Virgin Islands also participate in Medicaid, and therefore, providers must comply with the same screening requirements as United States Medicaid providers.

I. A Closer Look

Through our research, we analyzed and compiled the exclusion screening requirements in Puerto Rico, the U.S. Virgin Islands, the Northern Mariana Islands, and Guam. A summary for each territory follows.

II. Puerto Rico

Puerto Rico’s Medicaid program does not maintain a separate excluded provider list and does not demand that providers conduct independent exclusion screening. Instead, private companies, like Molina Healthcare, which contracts with Puerto Rico Medicaid, conduct exclusion screening searches before accepting a provider’s Medicaid enrollment application. The contracted healthcare company continually reviews review the exclusion lists monthly thereafter.

III. The U.S. Virgin Islands

The U.S. Virgin Islands, on the other hand, require providers to disclose quite a bit of information pertaining to exclusions. When a provider enrolls in the Virgin Islands’ Medicaid program, he must disclose whether: the provider; any person or entity that has a direct or indirect ownership interest of 5% or more of the provider; any person or entity with an interest in any subcontractor that the provider has an ownership interest of 5% or more; any agent, officer, director, or managing employee has ever been excluded from participation in any program under Medicare, Medicaid, or Title XXI services since the inception of the program.

In addition, the provider must certify that the enrolling provider, its owners, managers, employees, and contractors are not excluded from participation in the federal health care programs by checking the LEIE at the time of enrollment, before hiring or contracting, and monthly thereafter. The provider must also agree to immediately report any exclusion information discovered to the Department of Human Services.

IV. Northern Mariana Islands

The Northern Mariana Islands, like the U.S. Virgin Islands, address exclusions within the Medicaid Provider Enrollment application. Specifically, the provider must disclose whether he or she has ever been denied, terminated, or suspended by Medicare or any Medicaid program.   In addition, the provider must disclose whether any person with an ownership or control interest or any agents or managing employees have ever been convicted of a criminal offense related to his or her involvement in the federal health care programs, the commission of which would likely result in exclusion from participation in the programs.

V. Guam

Guam’s State Medicaid Plan, effective January 1, 2012, requires that the Medicaid agency performs exclusion screening checks on all providers, any person with an ownership or control interest in the provider, or any of the provider’s agents or managing employees.

VI. Takeaway

The U.S. Territories, much like the fifty states, have varied exclusion screening requirements.   We believe all providers must be aware of the specific requirements imposed by their state Medicaid office, but also believe that providers should not stop at their state’s baseline minimum for exclusion screening. Compliance is always the best policy and screening all available state lists is an excellent way to ensure that your practice is abiding by any requirements imposed by Medicare, Medicaid, or private insurance companies. In addition, when it comes time to enroll or re-enroll (and upcoming deadline for many) in your state Medicaid program, you can certify with confidence that no employee, contractor, or vendor has ever been excluded from participation in any state. 

Are you taking the necessary precautions to ensure you are not working with an excluded entity? We know it can be difficult to screen every Federal and State exclusion list. Call Exclusion Screening at (800) 561-0798 or fill out the form below to hear about our cost-effective solution and for a free quote and assessment of your needs.