New CMS Preclusion List Deadlines Loom

Centers for Medicare & Medicaid Services (CMS) sent a memo in November providing updated guidance regarding the Preclusion List requirements. This was addressed to all Medicare Advantage Organizations, Part D Plan Sponsors, 1876 Cost Plans and Programs of All-Inclusive Care for the Elderly (PACE). The aforementioned Medicare Plans and Part D Plan Sponsors were given a timeline when they must remove providers included on the Preclusion List from their network. This also served notice that beneficiaries or enrollees receiving care or a prescription from such providers must be informed.

Brief explanation

A Preclusion List is defined as: “A list of providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries.”

Those who can be included on the Preclusion List could either be individuals or entities. Generally, they would either be presently removed from Medicare or acted in such a way that would cause their removal had they been enrolled. In either case, the CMS must decide that such cause or behavior is inimical to the Medicare program. A notification and appeal process will be available to providers prior to inclusion on the Preclusion List.

The Preclusion List was created for two reasons:

  • To dispense with enrollment prerequisites for Medicare Advantage (MA) and prescribers
  • To secure and safeguard patients as well as Trust Funds from sanctioned prescribers and providers

Roles and responsibilities

The CMS letter reiterated that providers and entities included on the Preclusion List cannot receive payment. Medicare (insurance) Plans and Part D Plan Sponsors must be diligent in screening this list to ensure that they are paying qualified parties. They will not get reimbursed for any services rendered by a disqualified provider or entity. A beneficiary or Medicare enrollee claiming reimbursement for a Part D drug prescribed or service rendered by a party on the Preclusion List will be rejected. 

Medicare Plans and Part D Plan Sponsors were given a timeframe to remove those on the Preclusion List from their network. This will begin when the first Preclusion List is made available to the public on January 1, 2019. They must finish reviewing this by January 31, 2019. The CMS has stated that it will update the Preclusion List every 30 days. It will be available on the first business day of every month thereafter.

Prompt compliance

Medicare Plans and Part D Plan Sponsors must immediately inform beneficiaries who received a prescription or service from providers on the Preclusion List within the last 12 months. This would result in the denial or rejection of their claims under such provider. The beneficiaries however are not left without recourse. They are given an opportunity to seek out other providers that are not on the Preclusion List as replacement. Medicare Plans and Part D Plan Sponsors were advised to give beneficiaries 60 days to prepare prior to denying payments or rejecting claims.

This 60-day grace period begins after the Preclusion List is reviewed or posted, which is on January 31, 2019. Beneficiaries are given between February 1, 2019 to March 31, 2019 to make the necessary adjustments. Denials or rejections for reimbursement claims may be initiated on April 1, 2019 for the January 1, 2019 Preclusion List. This will allow sufficient time for all parties concerned to prepare. Note that Medicare Plans and Part D Plan Sponsors may no longer seek reimbursement beginning April 1, 2019. This applies to claims rendered by individuals or entities found on the January 1, 2019 Preclusion List.

The Streamline Verify system is prepared to set this up as soon as such Preclusion List is made accessible to Medicare Plans and Part D Plan Sponsors on January 1, 2019 . Find out what arrangements need to be undertaken to get ready for its approaching implementation date. Remain compliant and secure your business interests by contacting us today.

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