Tag: medicaid

Excluded in One Excluded in All

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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

Risk: It’s All About Time!

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Medical Provider data with regards to Medicare and Medicaid exclusions can be tricky from a timing perspective. Even though the Office of Inspector General (OIG) with the List of Excluded Individuals and Entities (LEIE) were created to attack the ever changing problem of Medicare Fraud, it can often be a trailing indicator. There are rules of inclusion that require the OIG to follow a process that often takes time. Once a name or entity is entered into the data set, it is only a matter of checking the names against the dataset either through the government website, downloading the data or using a Consumer Reporting Agency (CRA) or similar service.

The OIG is focused on this issue and does a good job to keep the data up to date as possible and it is a large effort indeed considering the estimate of Medical licensed professions is just under 12 million according to the most recent estimates.

But what about the risk of those organizations that hires or does business with individuals or entities who have been convicted of a crime or state boards who have taken action but the license is unaffected or the OIG has not issued an exclusion? What is the time factor of when the offender or subject shows up on the LEIE list? Or are the various State Medicaid lists timelier? Not all states have Medicaid sanctions lists but the number has grown to 37 states with the recent addition of Iowa and Georgia this year.

Let’s take for example the case of CNA Kenisha Abeene. Her name showed up on the Nevada List of Sanctioned Excluded Providers in early 2014. Her name did not appear on OIG until January of the following year.

As a matter of process, TyphoonDATA pulls press releases from various Law Enforcement sites, both state and federal to gauge how fast the issues get across the spectrum of reporting entities which include Federal sources like OIG, DEA Disbarment, SAM.gov and state exclusion sites like https://dch.georgia.gov/georgia-oig-exclusions-list. Also the issues might initially surface in Licensing repositories like Department of Professional Licensing or DOPL (pronounced “Dop-Pull”) or specific board sites. Unfortunately, the states are not uniform in the approach to posting and size does matter with regards to provider type licenses. There are more Doctors and Nurses in this country so often those boards have daily updates.

For example, in the case of Physician Cyrus Sajadi, Dr. Sajadi was charged in 2012 and his name was all over the DOJ and other news sites. But, there was no action granted until 2015. Meaning his license stayed clear and without action for three years, making it possible for him to practice when he was known to have committed fraud. Leaving any organization that hadn’t known of his fraud opens them up to potential risk. For three years, his name did not pop up on the OIG or any state exclusion site. Knowing as much about your employees or potential employees as possible will cut away at your exposure to fraud or potential fines.

Moving from state to state also presents challenges. Doing a Social Security (SSN) trace often reveals multiple states the subject has lived, worked or studied. Name changes, especially in marital status, are also a driving issue. The exclusion is a post that is current at the time of posting and personal identifying information or Pii is needed to capture the action or exclusion. Often the board action is “thin file” or lacking identifiers so Sherlock Holmes will be needed to crack the case.

And last but not least this is not a one and done issue. Continuous monitoring not periodic batching is recommended. The on-going update process of data should be at a minimum monthly and some sites (Medi–CAL) have some provider types where daily updates are done.

Here are examples of delayed reporting:

INDIVIDUAL

PROVIDER TYPE

DATE OF BOARD ACTION

DATE OF APPEARANCE IN THE OIG LEIE

H, AMBER DAWN

Pharmacy Technician

10/25/2013

1/20/2015

B, BENJAMIN

CNA

12/22/2014

5/20/2015

P, THOMAS A

Pharmacy Technician

11/22/2013

1/20/2015

A, DAVID

LPN

5/15/2006

8/20/2006

A, KENISHA

CNA

3/27/2014

1/20/2015