To understand the North Carolina Exclusion Screening Requirements, we must first touch upon Exclusions in general. Office of Inspector General (OIG) exclusions are one of the most powerful weapons available to the law enforcement in its efforts to fight healthcare fraud. Individuals and entities subject to an OIG exclusion are barred from participation in all Federal healthcare benefit programs, resulting in a payment prohibition on all items and services they provide, whether directly or indirectly. Additionally, providers that employ or contract with excluded individuals or entities risk the imposition of civil money penalties, overpayment liability, and even potential exposure under the False Claims Act. However, even though OIG exclusions are one of law enforcement’s oldest tools, many providers often fail to appreciate their compliance obligations and the risks associated with employing or contracting with excluded individuals or entities. Indeed, many providers take only minimal efforts to screen their employees and contractors to ensure compliance—and some make no effort at all.
In addition to the Federal Exclusion List hosted by the OIG, individual states are allowed to create their own State Medicaid Exclusion Database. North Carolina is one of the 42 States (including the District of Columbia) that host their own list and therefore have their own Exclusion Screening Requirements. This article seeks to educate providers on the existing legal and regulatory framework, the risks and potential consequences of a failure to comply with those laws and regulations, and how best to comply and avoid those risks.
Are you unsure your screening requirements depending on your business and location? Our FREE Consultation has you covered. It includes: An overview of exclusions in addition to an overview of your specific requirements and obligations. Furthermore a demonstration of our product and service (SAFER) will be performed prior to a presentation of your personalized solutions. This consultation is a free of charge consultation for your benefit only!
What is an Exclusion in North Carolina
According to the North Carolina Department of Health and Human Services (NCDHHS) website, an exclusion in North Carolina is defined as: “An excluded provider is one who is barred from participation in Medicare and/or other healthcare programs, like Medicaid, due to program violations. An excluded provider is not entitled to bill or be reimbursed for medical services provided to any federal or state healthcare program beneficiary. DHHS works diligently to prevent excluded providers from participating in NC Medicaid and NC Health Choice to comply with federal regulations.”
Similar to many other states, the NCDHHS also reports its excluded individuals and entities directly to the OIG HHS for including on the OIG List of Excluded Individuals and Entities. The list maintained by North Carolina is updated on a monthly basis and an individual or entity remains excluded until their name is removed from the list.
Which Exclusion Databases Should Be Screened?
The basic rule, as set out in Section 6.e. of the North Carolina Medicaid “Provider Administrative Participating Agreement,” is that the provider agrees to screen all its employees, contractors, and contractor’s employees on a monthly basis against the List of Excluded Individuals/Entities (LEIE) database to determine whether any of its employees, contractors, and contractor’s employees are excluded from participation in Medicare, Medicaid, or other federal health care programs. Contractors and subcontractors of enrolled provider are held to the same disclosure and reporting requirements, though the provider appears to be responsible for their screening.2
Enrollment/Reenrollment Requirements that Impact Exclusion Screening
As with many states, the enrollment and/or reenrollment process in North Carolina’s Medicaid Program has requirements that create exclusion screening obligations on the part of providers.
In North Carolina, providers must answer whether any managing employees or agents (in addition to owners) have been excluded from “Medicare, Medicaid, or any other government or private health care insurance program in any state,” or whether they have been employed by an entity that has been excluded from Medicare, Medicaid, or any other health insurance program in any 3
As managing employees and agents are broadly defined,4 providers should be mindful of who is placed on the disclosure list, and the fact that the disclosure relates to all state programs. In other words, a provider’s the exclusion screening obligation extends to all persons listed on the disclosure list. This obligation likely includes screening each person listed on all state Medicaid exclusion lists prior to executing the Provider
The North Carolina User Guide specifically advises that providers seek legal counsel on the reporting obligations for adverse actions that related to managing employees and
When implementing an exclusion screening program in North Carolina, providers should consider the implications of the screening obligations that arise out of the enrollment application as well as the monthly exclusion screening requirements.
2 NC DHHS Provider Administrative Participation Agreement (6)(e).
3 NCTracks User Guide – Exclusion Sanction Information, List of Sanction Questions
4 Managing employees are defined as managers, administrators, directors or anyone with operational or managerial control; or anyone who directly or indirectly conducts the day-to-day operation. Anyone who may obligate the provider and all officers, directors and board members are considered agents by the Provider Agreement.