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Medicaid Exclusion Checks

March 17, 2014 2 Comments

CMS issued a State Medicaid Director Letter (SMDL)  in 2009 recommending that States require providers to screen all employees and contractors monthly.  However in 2011, CMS issued final regulations mandating States to screen all enrolled providers monthly.   Furthermore Section 6501 of PPACA requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another States Medicaid program.  This becomes the “excluded in one, excluded in all” principle.

So what is the skinny of Medicaid exclusions checks in terms of best practice?  If you are providing services to Medicaid recipients in your state, you should determine if your state has specific screening requirements for exclusions and sanctions, and whether the State maintains its own database, or has uploaded their data to the OIG List of Excluded Individuals and Entities. (LEIE).    The OIG Exclusions list was a topic of our last post.

Medicaid Exclusion Checks Best Practice

According to David Servodidio of Provider Trust there are currently, 27 state Medicaid exclusion lists that exist.  And, in theory, according to Servodidio,  all of these lists should report all exclusions to the OIG LEIE on a timely basis.  Provider Trust did some research (he describes it as digging) and came up with the following:

Many of the state Medicaid exclusion lists do not report to the OIG LEIE on a timely basis, or at all. As an industry leader in health care compliance, we decided to put together a list of the best and worst state medicaid exclusion lists, based on how reliable they are to report to the OIG on a timely basis.  Let’s start with the best. When it comes to reporting excluded individuals to the OIG, here are the top State Medicaid exclusion lists:

  • Hawaii – 88%
  • Connecticut – 69%
  • Maryland – 60%
  • Nevada – 59%
  • Michigan – 55%

Here are the worst State Medicaid Exclusion Lists when it comes to reporting excluded individuals to the OIG on a timely basis:

  • West Virginia
  • Alabama
  • Indiana
  • Nebraska
  • Tennessee
  • Massachusetts
  • South Carolina
  • Washington

The bottom line:  checking the OIG database is not enough to ensure compliance with Medicaid exclusion checks.  You may have to check all available state Medicaid exclusion lists on a monthly basis in addition to the OIG exclusions database when hiring new employees.  Keep in mind the scalability of this to your clinic and organization.  Larger providers may want to avail themselves of a service, such as Provider Trust if there is a large employee base, and/or a monthly turnover.  Smaller providers likely need only to check upon hiring and annually.

Ensure your compliance strategy and monitoring and auditing plant covers all potential sources for exclusions on a monthly basis, and that would include all current (27) State Medicaid Exclusion Lists.

Do you provide Medicaid services?  Have you verified all your employees against your State Medicaid Exclusion List (for the 27 that exist).  Are you documenting your compliance with exclusion verifications?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (2)

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  1. Great content Nancy. Thank you for mentioning the research of my co-worker here at ProviderTrust. We have made some updates to the research and I would love to fill you in. Currently there are now 34 states exclusion list, as oppose to 27. To learn more about this visit our blog post title: 5 Things You Should Know About OIG Exclusions >> http://blog.providertrust.com/blog/bid/354149/5-Things-You-Should-Know-About-OIG-Exclusions)

    You may also view our case study on the importance of checking state lists >> http://providertrust.com/Case%20Studies

    Thank you! Feel free to contact us anytime.

  2. HI Jamie – and thanks for commenting. I just downloaded the ProviderTrust September webinar and actually sent info along to a provider as they were struggling with doing Medicaid checks, and wondering if only to do in state in which they had a presence… Another provider reported experiences with applicants who have been excluded from a licensure board in one state, then getting probationary licenses in other states (so therefore permitted to practice). As you know, the OIG has placed great importance on exclusion checks, but many small providers don’t understand the compliance necessity to do checks even if they feel they know their staff well, and haven’t had much change over. I look forward to talking to you in the next few weeks… And once again thank you for you comments and the links to your important messages on exclusion checks. My new favorite expression:”excluded in one, excluded in all..”

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