Category: CMS

The Medicare Exclusion Database (MED) and You

We are often asked if we have the Medicare Exclusion Database (MED) in our system. We do not collect the MED directly from CMS, but we do have this data in our system. The reason for this is because we collect our data from the primary source, as the Office of Inspector General is the primary source, we do not see a need to collect this data from the CMS as well.

We are precise in our collection. We believe in quality over quantity here at Typhoon Data. We don’t see a need in collecting “Everything”. Instead, we collect the pertinent, actionable, and primary source records that can help you and your clients get a full and complete picture on your health care providers. We take pride in our knowledge of these sources.

Last week, we got official and final confirmation that collecting the MED is not necessary.

Exact verbiage from CMS in regards to the MED:

“The Medicare Exclusion Database (MED) is a national database populated with information from the Office of the Inspector General.”

Excluded in One Excluded in All

Terminated-copy

Excluded in one, Excluded in all

The Affordable Care Act section 6501 discusses “Termination” of a medical provider under Medicaid if Terminated Under Medicare, CHIP, or Other State Plan.

“Termination occurs when the Medicare program, a State Medicaid program, or CHIP has taken an action to revoke a provider’s billing privileges, a provider has exhausted all applicable appeal rights or the timeline for appeal has expired, and there is no expectation on the part of a provider or supplier or the Medicare program, State Medicaid program, or CHIP that the revocation is temporary. The requirement for termination based upon a termination in another program applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing privileges revoked for cause which may include reasons based on fraud, integrity, or quality.”

We find important clarifying details in an informational bulletin published in May of 2011. One point made by the director of the CPI (Center for Program Integrity) addresses the “for cause” portion of this section. The statement reads “For cause may include, but is not limited to, termination for reasons based upon fraud, integrity, or quality. For cause does not include cases where a State terminates a Medicaid or CHIP provider as a result of a failure to submit claims due to inactivity.” Additionally if a provider voluntarily ends participation in the program this is not considered “for cause” except when the “voluntary” action is taken to avoid sanction. The end of billing privileges does not necessarily result in Termination

Another important clarification from this bulletin is that if a provider is “Terminated” in one state, then all other states must also terminate, and the duration of the termination should follow the terminating State’s law. They provide the following example for clarification; “State A terminates a provider and the length of termination is 3 years. A termination action is triggered in State B with regard to that same provider as a result of the State A termination action. State B’s length of termination is 1 year. The provider is not allowed to re-enroll in State B’s Medicaid program for a 1-year period as opposed to State A’s 3-year bar to re-enrollment.” We usually refer to this as the excluded in one excluded in all scenario.

A couple of other points worth mentioning. It is clarified that there is a difference between termination and exclusion. Termination happens at the state level for the reasons stated above. “Generally, “exclusion” from participation in a federal health care program, including Medicare, Medicaid, and CHIP is a penalty imposed on providers and suppliers by the Department’s Office of Inspector General (HHS-OIG). Individuals and entities may be excluded from participating in federal health care programs for misconduct ranging from fraud convictions to patient abuse to defaulting on health education loans.” While they are technically different situations the end result is the same, a provider’s involuntary departure from the Medicaid program or CHIP. Finally the information should be reported on at least a monthly basis to the HHS-OIG.

Want to review the bulletin? Here’s the link; https://downloads.cms.gov/cmsgov/archived-downloads/CMCSBulletins/downloads/6501-Term.pdf

Let’s Talk about Primary Source Data

What is a Primary Source?

A Primary Source is the original source repository or the source that legally issue licenses, discipline, education, training, or examination. A couple of examples of this in our industry are:

California Board of Registered Nursing
Office of Inspector General, U.S. Department of Health and Human Services (OIG)
Pharmacy Technician Certification Board (PTCB)
Centers for Medicare and Medicaid Services (CMS)

What is a Primary Source Data?

Primary Source Data is the license, certification, or disciplinary data directly from the original source. This means the data we collect is directly from the primary source. This data includes exclusion information, opt-out affidavits, license issuance, and disciplinary records. Another caveat to primary source data is we do not change, adjust, or modify the record found at the primary source.

Why is Primary Source Data Important?

Primary source data is important to your company as a way to confirm that your employee can be authorized to work for your facility.

The OIG has the authority to exclude individuals and entities from participation in federal healthcare programs. Any organization or individual who hires excluded parties may be subject to civil monetary penalties (CMP). To avoid these penalties, the LEIE recommends (as a part of the Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs) that you check their database upon hire, and on an ongoing monthly basis.

Primary Source data is not only important to us, it’s important to accrediting bodies (i.e. The Joint Commission, URAC) and exclusion bodies (i.e. OIG, GSA).