New CMS Preclusion Explained

Breaking Down the Numbers

The CMS Preclusion List has been live for 11 months now and its time to take a look at the numbers. Below is a breakdown for each state of how many businesses and individuals were listed each month.

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 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.

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. The Preclusion List was first made available to the public on January 1, 2019. They were required to finish reviewing this by January 31, 2019. The CMS has since updated the Preclusion List every 30 days on the first business day of every month.

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.

In the case of  individuals or entities found on the January 1, 2019 Preclusion List, 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. 

The Streamline Verify system is been screening the CMS Preclusion List ever since it was made available 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.

About Frank Strafford