Medicaid Exclusion Checks

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CMS issued a State Medicaid Director Letter (SMDL)  in 2009 recommending that States require providers to screen all employees and contractors monthly.  However in 2011, CMS issued final regulations mandating States to screen all enrolled providers monthly.   Furthermore Section 6501 of PPACA requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another States Medicaid program.  This becomes the “excluded in one, excluded in all” principle.

So what is the skinny of Medicaid exclusions checks in terms of best practice?  If you are providing services to Medicaid recipients in your state, you should determine if your state has specific screening requirements for exclusions and sanctions, and whether the State maintains its own database, or has uploaded their data to the OIG List of Excluded Individuals and Entities. (LEIE).    The OIG Exclusions list was a topic of our last post.

Medicaid Exclusion Checks Best Practice

According to David Servodidio of Provider Trust there are currently, 27 state Medicaid exclusion lists that exist.  And, in theory, according to Servodidio,  all of these lists should report all exclusions to the OIG LEIE on a timely basis.  Provider Trust did some research (he describes it as digging) and came up with the following:

Many of the state Medicaid exclusion lists do not report to the OIG LEIE on a timely basis, or at all. As an industry leader in health care compliance, we decided to put together a list of the best and worst state medicaid exclusion lists, based on how reliable they are to report to the OIG on a timely basis.  Let’s start with the best. When it comes to reporting excluded individuals to the OIG, here are the top State Medicaid exclusion lists:

  • Hawaii – 88%
  • Connecticut – 69%
  • Maryland – 60%
  • Nevada – 59%
  • Michigan – 55%

Here are the worst State Medicaid Exclusion Lists when it comes to reporting excluded individuals to the OIG on a timely basis:

  • West Virginia
  • Alabama
  • Indiana
  • Nebraska
  • Tennessee
  • Massachusetts
  • South Carolina
  • Washington

The bottom line:  checking the OIG database is not enough to ensure compliance with Medicaid exclusion checks.  You may have to check all available state Medicaid exclusion lists on a monthly basis in addition to the OIG exclusions database when hiring new employees.  Keep in mind the scalability of this to your clinic and organization.  Larger providers may want to avail themselves of a service, such as Provider Trust if there is a large employee base, and/or a monthly turnover.  Smaller providers likely need only to check upon hiring and annually.

Ensure your compliance strategy and monitoring and auditing plant covers all potential sources for exclusions on a monthly basis, and that would include all current (27) State Medicaid Exclusion Lists.

Do you provide Medicaid services?  Have you verified all your employees against your State Medicaid Exclusion List (for the 27 that exist).  Are you documenting your compliance with exclusion verifications?

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Nancy J. Beckley is the president of Nancy Beckley & Associates LLC, a firm specializing in outpatient therapy compliance. The firm offers compliance outsourcing, risk assessment, compliance plan development, annual compliance training, and external auditing, due diligence and investigation support. Clients include providers under Medicare probe review, progressive corrective action plans, corporate integrity agreements, ZPIC investigations and RAC audits.

Nancy’s background includes 15 years hospital experience serving in management capacities at two large inpatient rehabilitation facilities with extensive managed care contracting and program management expertise. A therapist by background and training, Nancy has served as program director, facility director and administrator in both inpatient and outpatient rehabilitation facilities.

She is a nationally known speaker in the area of rehab compliance, and has presented at the Provider Practice Compliance Conference, Florida Compliance Conference, and the Healthcare Compliance Association Compliance Institute. She was featured in a Healthcare Compliance Association webinar on Hospital Risks in Outpatient Therapy, and has authored three articles for Compliance Today and written over 20 articles on the RAC program.

Ms. Beckley’s area of expertise includes:

• Compliance program development, consulting, training, and external auditor

• Medicare regulatory requirements for outpatient therapy providers, including extensive experience in Medicare survey and certification for outpatient therapy providers

• Audit and consulting engagements under attorney-client privilege for risk assessment and potential payback liability analysis

• Medicare program integrity initiatives: MACs, RACs, CERT, ZPIC, probe reviews, pre and post payment reviews

• Nationally recognized expert on CORFs, served on the Medicare CORF Technical Expert Panel

• Hospital outpatient compliance consulting, auditing & training

• Compliance due diligence activities in acquisition and portfolio development to assess Medicare compliance risk

EDUCATION: University of South Florida, M.B.A.; Harvard University School of Public Health Course for Managed Care Executives; University of Illinois, M.S.; University of Wisconsin, B.S.

PROFESSIONAL ASSOCIATIONS: Board of Directors, National Association of Rehab Agencies (NARA); Member, Healthcare Compliance Association; Senior Contributing Editor, RAC Monitor + Monitor Mondays; Compliance Columnist for APTA’s IMPACT Journal

PROFESSIONALCERTIFICATIONS: CHC, Certified, Healthcare Compliance by the Healthcare Compliance Certification Board

PUBLICATIONS & PRESENTATIONS: Available upon request

CONTACT: 414-748-4376; [email protected];

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