Massachusetts Medicaid Exclusion Screening Requirements

Massachusetts Medicaid Exclusion Requirements


Massachusetts Medicaid Exclusion Screening:
Requirements and Best Practices for Compliance 

The Massachusetts Medicaid Exclusion requirements, under MassHealth, will not reimburse any item or service furnished directly or indirectly by individuals or entities that have been excluded from any State or Federal health care programs. This broad “Payment Prohibition” is enforced by the Massachusetts Executive Office of Health and Human Services, Office of Investigation General (MA-IOG) through rigorous exclusion screening requirements and the threat of civil money penalties and overpayment liability. This article discusses the exclusion screening obligations that providers of Medicaid services in Massachusetts must comply with, and it suggests best practices to promote compliance.

What is a Medicaid Exclusion?

“Exclusions” are final administrative actions by State or Federal agencies that bars all participation in a sponsored benefit program. When a State bars and individual or entity from participating in its Medicaid program, that is typically referred to as a “Medicaid Exclusion;” similarly, when someone is barred from the Medicare program, that is commonly referred to as a “Medicare Exclusion.” Massachusetts is one of the 41 States that maintains its own exclusion list (DC also has one), and it can be found on the MassHealth website at The OIG’s “List of Excluded Individuals and Entities” (LEIE) contains the federal Medicare Exclusions, and it is maintained on the OIG website at States without their own exclusion lists rely on the LEIE.

Who Gets Excluded? Why are Exclusions Imposed?

The primary reasons for MassHealth to exclude a party, as found on its website, are as follows:

  • Not complying with participatory requirements of the MassHealth program.
  • Being excluded under Medicare.
  • Suspension of exclusion by any other state Medicaid agency.
  • Having an inactive, terminated, suspended, or revoked license or authorization to provide services.
  • Conviction of health care fraud.
  • Pleading guilty to or being convicted of criminal activity materially related to Medicare or Medicaid.
  • The U.S. Department of Health and Human Services initiated an action that is binding on the provider’s participation in the Medicaid program. See, .

What is the Effect of a Medicaid Exclusion?

Stated simply, exclusions are intended to virtually eliminate the ability of an individual or entity to continue to receive funds from State or Federal healthcare benefit programs.

Massachusetts Medicaid Exclusion 

A provider suspended from MassHealth due to an exclusion is, “not eligible to participate… [and] cannot receive payments for any services” until they are reinstated in the program, 130 CMR 450.217.  This sanction is commonly referred to as a “Payment Prohibition,” and it mirrors the ban imposed by the Health and Human Services.

    Further, as noted in MassHealth’s All Provider Bulletin 196.

    “federal regulation prohibit MassHealth from paying for any items or services furnished, ordered, or prescribed by the excluded individual or entity. The payment prohibition bars:

    • Direct payment to excluded individuals and entities;
    • Payment to individuals or entities that employ or contract with excluded individuals or entities; and
    • Payment for administrative and management services furnished by excluded individuals or entities that are not directly related to patient care, but are a necessary component of providing items and services to MassHealth members.”

    The limitation on reimbursements extends to all services whether they are reimbursed directly or indirectly and regardless to whether they are a pay per service or part of a bundled payment. For example, they include services performed by excluded pharmacists, excluded individuals who input prescription information for pharmacy billing, or persons involved in any way in filling prescriptions for drugs reimbursed by a Medicaid program. It also includes services performed by excluded administrators, billing agents, accountants, or utilization reviewers if their services are reimbursed, directly or indirectly, by a Medicaid program; and items or equipment sold by an excluded manufacturer or supplier (See, the All Provider Bulletin 196 and the OIG’s 2013 Special Bulletin on the Effects of Employing Excluded Parties.),

    Additionally, pursuant to Section 6501 of the Affordable Care Act, States are required to terminate the participation of any provider that has been terminated “for cause” by any other State Medicaid program. This is intended to strengthen Medicaid programs by stopping providers that are excluded in one State from moving to another and providing services there, and even though some states have been slow to enforce this provision, an exclusion for cause imposed by MassHealth is a basis for exclusion by every other state, and the exclusion for cause by any other State Medicaid Program is grounds for exclusion in Massachusetts. Thus, an excluded individual is truly radioactive when it comes to providing services in Massachusetts or in any other State or Federal Health Benefit Program.

    Provider Exclusion Screening Requirements:

    MassHealth imposes rigorous “exclusion screening” requirements which, as will be seen arise from more than one source. Providers that fail to meet their screening obligations risk overpayment liability, penalties, and suspension or termination from the program. Larger providers should also be aware that each State has its own separate set of screening obligations.

    Basic MassHealth Exclusion Screening Obligations

    MassHealth’s baseline exclusion screening obligations are set forth in the All Providers Manual, Provider Bulletin #196. These requirements are consistent with those outlined by CMS and HHS/OIG, and to comply with them providers of Medicaid services must:

    • Screen all employees and contractors with the OIG’s List of Excluded Individuals/Entities (LEIE), to determine if the OIG has excluded any of them from participation in federal health care programs,
    • Screen employees and contractors with the MassHealth Exclusion List,
    • Screen each individual or entity upon hire and monthly thereafter to ensure there hasn’t been a change in status, and,
    • Immediately report any discovered exclusion of an employee or contractor to the EOHHS Compliance Office. (See, MassHealth All Providers Bulletin #196, 2009, See also, State Medicaid Director Letter #09-001 issued by the Centers for Medicare & Medicaid Services (CMS).

    Additional Exclusion Screening Obligations Imposed by MassHealth

    In addition to the basic requirements outlined above, the MassHealth enrollment and re-enrollment process, and the disclosure requirements that accompany them, created additional exclusion screening obligations that providers need to be aware of. Specifically, providers seeking to enroll in MassHealth must identify all direct and indirect owners, agents, managers, and any other “Medicaid disclosing entity” and disclose if they have ever been excluded from participation in Medicare or any of the state health care programs. Similarly, providers must notify “MassHealth agency whenever it has notice of a termination or suspension from participation in Medicare or another state’s Medicaid program;” (See, 130 CMR 450.212(A)(6), 130 CMR 450.215 and the MassHealth Disclosure Form which is found on the MassHealth website).

    Finally, MassHealth requires applicants to “certify sign under the pains and penalties of perjury,” that the information contained in the application and the disclosure forms is true, accurate, and complete. If it’s not accurate the applicant, “may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.” It goes without saying that the only way for a provider to meet these requirements is by screening at the initiation of the relationship and monthly thereafter. This, again, can only be met by having a vigorous and effective exclusion screening program


    The Chief Counsel division of the Massachusetts Office of Inspector General is primarily involved in exclusion enforcement.  The General Law section within the OIG is responsible for taking initial actions that relate to excluding providers when required by federal law, and the Litigation Section actually processes provider enrollment terminations and exclusions.  The Medicaid Program Integrity division (MPI) may also be involved in investigating potential exclusions and referring them to the Litigation Section.  In addition to potential overpayment liability, violations can result in federal civil money penalty or criminal liability under § 1128A and § 1128B of the Social Security Act. Massachusetts may also include the imposition of triple damages and/or penalties up to $11,000 per false claim. See All Provider Manual Subchapter 2: Administrative Regulations; 130 CMR 450.217 ; See also, the Massachusetts AG site on False Claims  


    Best Practices for Compliance with Massachusetts Medicaid Exclusion Screening Requirements

    Compliance with exclusion screening requirements is critical. Providers that fail to ensure the exclusion status of their owners, managers, employees and contractors risk overpayment liability, the imposition of civil money penalties, and even possible criminal consequences.  Only proper exclusion screening can help providers mitigate or avoid these risks, and this section will suggest some practices that providers should consider including in their compliance plans.  

    A. Interpret the Requirement to Screen Employees, Vendors, and Contractors Broadly

    The OIG widely interprets employees, contractors and vendors to include those that provide direct and indirect services — and so should you. It is recommended that you include, for example, individuals and entities in the following roles or who perform the following functions:

    • Owners, directors, managers, administrators — anyone in a leadership role,
    • Anyone providing support or care either directly or indirectly,
    • Those involved in claims processing,
    • Transportation service providers,
    • IT and Security providers and their technicians,
    • Medical equipment suppliers, Pharmacies and their Pharmacists,
    • Agencies providing temporary direct services providers.
    See, All Providers Bulletin #196, 42 CFR 1001.1901(b), State Medicaid Director Letter #09-001 from the Centers for Medicare & Medicaid Services (CMS) and the OIG’s 2013 Special Bulletin.

    B. Screen Upon Hire or Contract Initiation, and Monthly Thereafter  

    As previously discussed, providers must screen upon hire and monthly thereafter. This is is the only way to ensure compliance with the obligation to ensure an exclusion-free workforce and, again, it is supported by All Providers Bulletin #196 and the State Medicaid Director Letter #09-001 from the Centers for Medicare & Medicaid Services (CMS).

    C. Screen the MassHealth Exclusion List, the LEIE, and all State Medicaid Exclusion Lists

    The only way to maintain compliance with both the obligations contained in the MassHealth regulations, the enrollment process and their disclosure obligations, and the provider’s ongoing obligation to notify MassHealth of exclusions, providers should screen all 41 State
    Exclusion Lists and the LEIE in addition to the MassHealth Exclusion List. It is also noted that this is an important practice in light of Section 6501 of the ACA.

    D. Don’t Forget to Include Owners, Officers, and Managers

    These folks must be identified and disclosed; their exclusion status must be “certified”; and providers must “update” any changes in that status. This can only be accomplished by including them on the monthly list.

    E. There are Special Rules for Billers and Coders

    Because they submit the claims, Billers and third-party billing companies receive “special attention” when it comes to exclusion screening. The OIG guidelines in the Advisory Bulletin states that providers should consider adopting some or all of them:

    • Requiring third-party billers to have a policy of not employing excluded persons and provide proof that it is, in fact, screening, and,
    • Requiring all billers to be trained in connection with the applicable requirements and preparation of the claims they are submitting

    F. Hire a Vendor to Fulfill Your Exclusion Screening Requirements 

    Some providers are able to perform the “basic” screening obligation of checking the Massachusetts Medicaid Exclusion List and the LEIE, but providers that attempt to screen all State and Federal Exclusion Lists are almost certainly going to find the task to be insurmountable. The difficulty stems from several factors: there is no uniformity in the list formats (they could be in WORD, Excel or PDF); each list contains different fields on information; States have different reasons and standards for including people on their list; and some States may have little to identify the person or entity beyond a name and city. In short, as with many other necessary services, providers will benefit from specialized assistance in meeting this regulatory obligation.

    For this reason, it is recommended that providers consider hiring a 3 rd party vendor to assist in screening. BUT, providers should be aware that vendor services, and the costs they charge, often vary widely. Thus, providers are urged to consider more than one vendor and to compare the specific services they will receive and the costs of each service. As part of this process, we hope that you will give Exclusion Screening the opportunity to demonstrate what it can do and how it can help.


    Closing Comments

    The goal of this article is to help providers gain a better understanding of the Massachusetts Medicaid Exclusion requirements and to provide suggestions on compliance best practices. As we have said, we believe that providers will benefit from specialized assistance in meeting this regulatory obligation, and we invite you to call or visit with us at Exclusion Screening to see if our state-of-the-art technology, ease of use can help you meet your exclusion screening compliance needs.

    For a look at other State Exclusion Databases click here! 

    If you are a provider in Massachusetts call us at 800-294-0952 or fill out the form below and see how we may be able to assist you and make this process a breeze.

    The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes only.  Information on this website may not constitute the most up-to-date legal or other information.  This website contains links to other third-party websites.  Such links are only for the convenience of the reader, user or browser; Exclusion Screening does not recommend or endorse the contents of the third-party sites.


    ZPIC AuditsIs Your Practice Being Audited by a ZPIC? Did You Know it Can Lead to an OIG Exclusion?

    Zone Program Integrity Contractors (ZPICs) are among the most aggressive program integrity entities employed by the Centers for Medicare and Medicaid Services (CMS).  As most healthcare providers are aware, ZPICs regularly place physician practices on prepayment review and sometimes conduct post payment audits of previously paid claims.  However, did you know that ZPICs are also supposed to play a role when it comes to “exclusions”

    According to Sec. of the Medicare Program Integrity Manual (MPIM) reflects, ZPICs are actually REQUIRED by CMS to review and evaluate cases to determine if they warrant exclusion action.  And if in its estimation exclusion is warranted, they must make a recommendation to the Office of Inspector General (OIG) for consideration.

    Section 2.2 lists a number of examples of the types of cases that would be suitable for the ZPIC to make an exclusion recommendation.  Some of them, such as convictions of program related offenses under (§1128(a)) and convictions related to patient abuse or the sale and use of drugs (§1128(b) are common sense and would likely have already resulted in the initiation of an exclusion action, but a number of others may surprise you.  Below you will find a partial list:
    • Providers who have a pattern of adverse QIO, AC, or MAC findings.
    • Providers whose claims must be reviewed continually and are subsequently denied because of repeated instances of overutilization.
    • Providers who have been the subject of previous cases that were not accepted for prosecution because of the low dollar value.
    • Providers who furnish or cause to be furnished items or services that are substantially in excess of the beneficiary’s needs or are of a quality that does not meet professionally recognized standards of health care (whether or not eligible for benefits under Medicare, Medicaid, title V or title XX).
    • Providers who are the subject of prepayment review for an extended period of time (longer than 6 months) who have not corrected their pattern of practice after receiving educational/warning letters.
    ZPICs that make exclusion recommendations are required to consider a number of factors and are supposed to consider alternatives in an effort to change the provider’s conduct.  And, of course, the final authority to exclude a provider from participation in Federal health benefits programs lies with the OIG.  But it is important for you to keep in mind that this is yet another risk area your practice may face in the event of a ZPIC audit. 

    Unfortunately, this is only one of the additional risks that your practice may face.  For additional information on ZPIC audits, we recommend you review the recent article by Robert W. Liles entitled “UPIC / ZPIC Referrals to State Licensure Boards, Professional Societies, State Surveyors, QIOs and to the OIG for Exclusion Consideration.”  it provides a nice preview on inter-agency referrals of complaints by ZPICs. 

    Have more questions about exclusions? Call Exclusion Screening at 1-800-294-0952 or fill out the form below to have your questions answered and to hear how Exclusion Screening can help you!

    About the AuthorCo-Founder, Exclusion Screening
    Paul Weidenfeld is a long time health care lawyer who has specialized in litigation arising out or, or relating to healthcare fraud and the False Claims Act. A former federal prosecutor and National Health Care Fraud Coordinator for the Department of Justice, Paul is a frequent speaker who has earned recognition both as a Federal Prosecutor and as a member of the private bar.  Paul is also a co-founder of 
    Exclusion Screening, LLC, a company that offers providers a simple, cost-effective way to meet their exclusion screening obligations.

    OIG Announces Creation of Special Unit for CMP and Exclusion Litigation

     Exclusion Screening, LLC has been chronicling the Office of Inspector General’s (OIG) interest in exclusion enforcement for quite some time. Hence, yesterday’s announcement that the OIG created a special litigation unit focusing on Civil Money Penalties (CMP) and Exclusions comes as no surprise to us.

    Only two weeks ago we published an article on the OIG’s increasing enforcement efforts. In that article we concluded that: “The evidence strongly supports the conclusion that OIG’s involvement in exclusion enforcement is increasing… [with] enforcement interest and involvement spread throughout the agency….” This followed a January article discussing increasing enforcement in 2014.

    There has been no formal announcement on the agency website. Therefore, the details of the unit are not yet known. On June 30, 2015, at the annual meeting of the American Health Lawyers Association, it was announced that the unit was actually formed in March. However, it is not yet fully staffed.


    Need to know more about what your organization needs to do in terms of screening for exclusions? Call Exclusion Screening at 1-800-294-0952 or fill out the form below for more information and to hear how Exclusion Screening can save your organization from civil monetary penalties. 


    OIG Exclusion

    Paul Weidenfeld, Co-Founder and CEO of Exclusion Screening, LLC, is the author of this article. He is a longtime healthcare lawyer whose practice has focused on False Claims Act cases and health care fraud matters generally. Contact Paul should you have any  questions at: or 1-800-294-0952.