CMS’ Preclusion List Policy Explained

Posted by Frank Strafford on July 5, 2018 in Industry News, Urgent,

The Centers for Medicare & Medicaid Services (CMS)’ Preclusion List went live Jan. 1, 2019. the 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.” This list precludes providers and prescribers who opted out of Medicare participation from receiving payment for Medicare Advantage services furnished to Medicare beneficiaries. The CMS has since updated the Preclusion List every 30 days on the first business day of every month.

The Preclusion List may include either individuals or entities. Generally, these individual or entities are listed due to factors such as acting in a way indicative of fraud, waste and abuse. These circumstances would cause their removal had they been enrolled. In either case, CMS must decide that such cause or behavior is detrimental to the Medicare program. There is a notification and appeal process available to providers prior to inclusion on the Preclusion List. CMS mandates Medicare Plans and Part D Plan sponsors are given a timeline when they must remove providers included on the Preclusion List from their network. Beneficiaries or enrollees receiving care or a prescription from such providers must be informed.

Roles & Responsibilities

The CMS letter reiterated that providers and entities included on the CMS Preclusion List cannot receive payment. It is in the best interest of Medicare and Part D Plan Sponsors to diligently screen this list to ensure that they are paying qualified parties as 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.

By the Numbers: Hover over each state to view a count of entities on the CMS Preclusion List for each month.

Part D (Prescription Drugs)

On April 1, 2019, CMS commenced issuing fines to providers if a drug was prescribed by an individual or entity on the Preclusion List. Part D sponsors are required to reject a pharmacy claim or deny a reimbursement request by an entity or individual on the Preclusion list.

Prompt Compliance

Medicare Plans and Part D Plan Sponsors must immediately inform beneficiaries who received a prescription or service from providers listed on the CMS 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 CMS 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.

Medicare Advantage Plans and Opioids Treatment Programs

CMS requires Medicare Advantage plans to deny payment to an individual or entity on the Preclusion List for a health care item or service provided to a beneficiary by the precluded individual or entity. Medicare Advantage Plans are “a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits (hospital services, doctor’s appointments.). Most Medicare Advantage Plans also offer prescription drug coverage.

On July 29, 2019, CMS welcomed opioid treatment programs Opioid Treatment Programs (OTPs) in Section 2005 of a new proposed rule. On January 1, 2020, CMS will pay OTPs through bundled payments for Opioid Use Disorder (OUD) treatment services in an episode of care provided to Medicare Part B beneficiaries. The law firm Bass, Berry & Sims PLC states “CMS proposes to classify OTPs as high risk for fraud, waste and abuse, meaning OTPs will be required to – among other things – submit fingerprints of all 5% or greater owners and be subject to site visits. CMS also proposes to restrict OTP employees and contractors.” They go on to add “OTPs would not be able to employ or contract with anyone revoked from Medicare, on the CMS preclusion list or with a current or prior state oversight board adverse action deemed by CMS as detrimental to the best interest of Medicare beneficiaries.” To enroll in Medicare, CMS in a letter to OTP Program Sponsors and State Opioid Treatment Authorities that “OTPs must be fully certified by the SAMHSA and accredited by a SAMHSA-approved accrediting body”.

The Streamline Verify system has been screening the CMS Preclusion List ever since it was made available to Medicare Plans and Part D Plan Sponsors on January 1, 2019. Remain compliant and secure your business interests by contacting Streamline Verify today.

About Frank Strafford

About Frank Strafford

Related Articles

2015: OIG Compliance Year in Review

January 6, 2016

How did healthcare compliance fare in 2015? Overall, it was quite a busy year for the OIG and various organizations, with noteworthy settlements and enforcement activities beginning as early as Januar...

Why Do Some Nurses Commit Fraud?

June 28, 2016

Nurse Fraud   Nurses have become heavily involved in a spate of health-care related fraud news in recent years. One of the most controversial reports of fraud from the Department of Justice wa...

ALERT: Data Discrepancies in GSA’s ...

August 16, 2021

The regular screening of federal lists for individuals who are ineligible to participate in federal contracts is required of all federal healthcare contractors. The OIG and SAM lists, as they are comm...