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