In 2018, CMS issued a Final Rule[i] that rescinded existing regulations which required providers of Medicare Advantage services and prescribers of Part D drugs to enroll in Medicare Fee-for-Service.[ii] Instead, providers and suppliers desiring to participate in Part C and / or Part D would enroll directly with the payor plans. As a safety measure and to protect the integrity of the Medicare Trust Fund, CMS created a register of all health care providers, suppliers and prescribers who are precluded from receiving reimbursement for items and services covered by Medicare Part C and Part D. CMS has referred to individuals placed on the “CMS Preclusion List” as “Bad Actors.”
[i] “Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program.” 83 FR 16440 (April 16, 2018).
[ii] Institutional providers and suppliers must still be enrolled in the Medicare-Fee-Service program. Additionally, as part of their credentialling requirements, some Medicare Advantage plans may require that a provider or supplier be enrolled in the Medicare Fee-for-Service program.
While the OIG’s “List of Excluded Individuals and Entities” (LEIE) is publicly available and is accessible by all Medicare providers and suppliers, the CMS Preclusion List is only available to Part C and Part D payor plans. As a screening agent for Part C and Part D payor plans, Exclusion Screening is authorized to access the CMS Preclusion List on behalf of these authorized payor plans.
Individuals and entities placed on the Preclusion List by CMS fall within two broad reasons. Placement on the CMS Preclusion List will typically be the result of a CMS revocation action[i] OR because CMS has decided that the provider’s underlying conduct or behavior would have led to the revocation is detrimental to the best interests of the Medicare program
[i] 42 CFR §424.535
In making this determination under this paragraph, CMS considers the following factors: (1) The seriousness of the conduct underlying the individual’s or entity’s revocation, (2) The degree to which the individual’s or entity’s conduct could affect the integrity of the Part D or the Part C Medicare Advantage program, and (3) Any other evidence that CMS deems relevant to its determination. Finally, it is important to keep in mind that OIG exclusions actions and felony convictions will also result in an individual or entity being placed on the CMS Preclusion List.
The length of time that an individual or entity can remain on the CMS Preclusion List depends on the underlying reason why the placement was first made. For example:
“Any individual or entity that is dissatisfied with an initial determination or revised initial determination that they are to be included on the preclusion list (as defined in § 422.2 or § 423.100 of this chapter) may request a reconsideration in accordance with § 498.22(a).” (Emphasis added).
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