7 Things You Need to Know About the CMS Preclusion List

Apr 15, 2020 | Compliance

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In 2019, the Centers for Medicare and Medicaid (CMS) published new rules for providers and plans. Among these new rules was the Medicare Preclusion List, which adds new restrictions on payments to certain providers.

Here’s what you need to know about the CMS Preclusion List, what it means for health care providers, and how to stay compliant.

Definition of the CMS Preclusion List

According to the Centers for Medicare and Medicaid (CMS), the Preclusion List is 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.

The Preclusion List applies only to Medicare Advantage items and services or Part D drugs for Medicare beneficiaries; the preclusion is at a Tax Identification Number (TIN) level. Individuals and entities will not appear on the Preclusion List unless all Medicare enrollments on their TIN are revoked or inactive.

Why Was the CMS Preclusion List Created?

One of the main functions of the Preclusion List was to replace the Medicare Advantage (MA) and prescriber enrollment requirements that existed previously. This was part of a larger overhaul on Medicare payment policies enacted to prevent waste and abuse and to streamline and improve the provider enrollment process.

Roles and Responsibilities of Providers

As with other exclusion lists and databases, compliance is crucial for health care providers. Individuals and entities who are listed on the Medicare Preclusion List cannot receive money from Medicare, so organizations need to screen their providers against this list regularly to make sure they are not billing charges from providers that are not eligible.

How Does a Provider or Entity End Up on the Preclusion List?

CMS publishes updates to the Preclusion List every 30 days. Based on the following criteria, a provider or entity is excluded if:

  • They are currently revoked from Medicare, under an active re-enrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program, or;
  • They have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare Program.

One of the important things to consider with the Medicare Preclusion List is that a provider or entity does not have to be revoked from Medicare to end up on the list.

Am I on the Preclusion List?

The Medicare Preclusion is not publicly available, but CMS will notify providers and entities when they are excluded. The process is as follows:

  • Providers receive an email and letter from CMS before inclusion on the Preclusion List
  • The email and letter are sent to the provider’s Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing
  • The letter will contain the reason for preclusion, the effective date of preclusion, and applicable rights to appeal

When Did the New Preclusion List Go into Effect?

The CMS Preclusion List was announced in April 2018, but the first provider list was published and notices were sent in January 2019. MA plans had until January 31, 2019 to remove providers from their plans.

Is the CMS Preclusion List the Same as the OIG’s Exclusion List?

The CMS Preclusion List is a different list from the OIG List of Excluded Individuals/Entities. While some individuals may end up on both lists, they are functionally different databases. It’s important to screen providers against both lists.

Since the CMS Preclusion List is not publicly available, it can be difficult for organizations to screen against it. Access is limited, and while individuals and entities on the list will receive a notification, that information is important for health care organizations and entities to know as well.

Verisys includes the CMS Preclusion List in its platform of over 3,500 primary sources for health care provider screening and credentialing. Our clients use our platform to perform initial screenings as well as ongoing exclusion monitoring of their organization, employees, vendors, and contractors to maintain patient safety and regulatory compliance.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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