When the Centers for Medicare and Medicaid Services’ (CMS) Medicare Preclusion List went into effect in 2019, it added restrictions on Medicare payments to certain providers. This article explains the CMS Preclusion List, its effect on healthcare providers, and the regulations organizations must follow to remain compliant.
What is the CMS Preclusion List?
The Preclusion List names 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.
Key details about the Preclusion List:
- It applies only to Medicare Advantage items and services or Part D drugs for Medicare beneficiaries.
- Providers are identified according to their Tax Identification Number (TIN).
- Individuals and entities will not appear on the list unless their Medicare enrollment is marked as “revoked” or “inactive.”
Why Was the CMS Preclusion List Created?
CMS created the Preclusion List with three main goals:
- To ensure that problematic prescribers do not receive payment for prescribing Part D drugs
- To reduce burdens on Part D and Medicare Advantage providers while maintaining program integrity
- To replace Medicare Advantage’s enrollment requirements
By removing these requirements, CMS estimated that it would save over $34 billion in 2019 alone.
Provider Responsibilities and Compliance
Compliance with the CMS Preclusion List is essential. Not only can you put your patients at risk by unknowingly hiring precluded providers, but you can also create financial problems for your organization by billing for services from providers on the Medicare Preclusion List who are not eligible for reimbursement. Regularly screening your providers against the list will help you avoid this mistake.
How Does a Provider or Entity End Up on the Preclusion List?
CMS updates the Preclusion List every 30 days, so organizations should check the list often. An entity or individual can be precluded for the following reasons:
- They are currently revoked from Medicare, under an active re-enrollment bar, and CMS has determined that their conduct is harmful to the Medicare program.
- They have engaged in conduct for which CMS would have revoked the individual or entity if they had been enrolled in Medicare, and CMS determines that this conduct is harmful to the Medicare Program.
A provider or entity does not have to be revoked from Medicare to appear on the list.
How to Check If You Are on the Preclusion List?
The Medicare Preclusion List is not publicly available, but CMS will notify providers and entities when they are excluded according to the following process:
- CMS will send an email, followed by a letter, to the provider
- 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) address
- The letter will contain the reason for preclusion, the effective date of preclusion, and any rights to appeal
CMS Preclusion List vs. OIG Exclusion List
The CMS Preclusion List is different from the OIG List of Excluded Individuals/Entities. While some individuals may appear on both lists, organizations should screen providers against both since they serve different purposes.
Since the CMS Preclusion List is not publicly available, healthcare organizations may face challenges in screening against it. Providers on the list receive direct notifications, but organizations also need access to this information to prevent hiring precluded individuals.
CMS Preclusion List FAQs
How long does a provider remain on the Preclusion List?
A provider will be precluded for as long as their re-enrollment bar lasts. The re-enrollment bar takes effect 30 days from the date the initial determination letter was issued. The preclusion period may last anywhere from one to ten years, depending on the offense. CMS may also add an additional penalty of a 20-year re-enrollment bar for second offenses.
Is Medicare Fee-for-Service enrollment required for Part D prescribers and providers participating in Medicare Advantage (MA)?
When CMS published CMS-4182-F, it removed the CMS enrollment requirement for both providers who prescribe drugs under Medicare Part D and for providers and suppliers that supply healthcare items or services through a Medicare Advantage (MA) organization.
Can a provider appeal their placement on the Preclusion List?
Yes, with limitations. 42 CFR Part 498 allows a provider to challenge their placement on the list but not the underlying reason for their appearance on the Preclusion List. If you receive notification of a Medicare revocation and your placement on the Preclusion List at the same time, you may challenge both simultaneously. The letter includes instructions on how to appeal. Send appeals by mail to the CMS provider enrollment group. Questions about the notification letter may be sent to CMS at providerenrollment@cms.hhs.gov
Can plan sponsors use their own letters containing the CMS information?
An HPMS guidance memo sent on November 2, 2018, contained a sample notice. Plan sponsors are not required to use the sample beneficiary notice when they notify beneficiaries about a provider’s placement on the preclusion list when they send notifications; however, every notice must give beneficiaries at least 60 days’ notice before denying claims and must include all required information.
If someone is enrolled in both Medicare and Medicaid and sees a precluded provider, who is responsible for payment?
The plan should follow the standard rules for coordinating benefits processing. Generally, Medicare is the primary payer and Medicaid is the secondary payer; however, if someone enrolled in both plans receives services from a precluded provider and the Medicare Advantage plan does not pay, the payment does not automatically transfer to Medicaid because these services are not covered by Medicare or the state.
Ensure CMS Preclusion List Compliance with Verisys
With the introduction of the Preclusion List, CMS has made healthcare safer for organizations and patients by ensuring problematic providers do not receive payment for their services. However, limited time resources and access to the list can make it difficult for organizations to check their providers against the Preclusion List and comply with all of CMS’s regulations.
Verisys includes the CMS Preclusion List in its platform of over 5,000 primary sources for healthcare credentialing. Our clients use our services to perform the initial medical pre-employment screening and ongoing exclusion monitoring of their organization, employees, vendors, and contractors to maintain patient safety and regulatory compliance. Use active healthcare compliance monitoring to stay ahead of potential credentialing expirations and changing industry standards.
