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 https://www.mass.gov/service-details/learn-about-suspended-or-excluded-masshealth-providers. The OIG’s “List of Excluded Individuals and Entities” (LEIE) contains the federal Medicare Exclusions, and it is maintained on the OIG website at https://exclusions.oig.hhs.gov/. 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, https://www.mass.gov/service-details/learn-about-suspended-or-excluded-masshealth-providers .
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.
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 MassHealthIn 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.
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.
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!