CMS Preclusion List FAQs

What is the CMS Preclusion List? The Centers for Medicare and Medicaid (CMS) defines the CMS Preclusion List as a record 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.

In 2018, the Center for Medicare and Medicaid reported saving $1.7 billion through Medicare Accountable Care Organizations (ACOs). Consequently, in April 2018, the Department of Health and Human Services released the Federal Register Rules and Regulations update which included policy changes on Medicare programs.

Under these updates, CMS found that the preclusion list was necessary to:

• Replace Medicare Advantage (MA) and prescriber enrollment requirements
• Ensure patient protections and safety, and to protect trust funds from prescribers and providers identified as bad actors

The first list of providers that were to be precluded was notified on January 1, 2019. Beginning on April 1, 2019, Part D sponsors and Medicare Advantage (MA) were required to reject or deny any prescriptions or payments for Medicare Part D drugs that were prescribed by an individual or entity on the CMS Preclusion List.

Individuals or entities who meet the following criteria can be found on the preclusion list:

1. The individual or entity is currently revoked from Medicare, are 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.
2. 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.

How Do I Know If I Am Precluded? 

If you are on the CMS Preclusion List, you will receive notifications with the reason you are precluded, the effective date of your preclusion, and your applicable rights to appeal in the following formats:

• An email and letter from CMS/Medicare Administrative Contractors (MAC) in advance of your inclusion on the CMS Preclusion List.
• An email and letter will be sent to your Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing.

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

While there is some overlap, the CMS Preclusion List is not the same as the OIG Exclusion list. The OIG Exclusion List comprises any individual or entity that poses unacceptable risks to patient safety or program fraud. The OIG Exclusion List includes individuals who have committed or are undergoing:

• Patient abuse
• Substance abuse
• License revocation or other permissive exclusions

As a federal fraud regulator, the OIG Exclusion List is publicly available through the Office of the Inspector General. More details about the OIG exclusion list can be found here.

How Can I Screen for Precluded Individuals or Entities? 

The CMS Preclusion List only includes individuals/entities whose conduct is detrimental to the interest of the Medicare Program. These individuals/entities who have committed and/or are currently:

• Revoked from Medicare
• Underactive re-enrollment bar
• Could be revoked if enrolled in Medicare

Access to the CMS Preclusion List is extremely restricted and not publicly available. However, Verisys includes the CMS Preclusion List in its database of over 3,500 primary sources for health care provider screening and credentialing.

All databases are regularly updated to ensure that your organization is always in compliance with credentialing. In order to maintain patient safety and regulatory compliance, clients use Verisys to perform both initial and ongoing provider screening and monitoring. Constant scanning and automatic updates save time and money so that your organization can get back to the real work — saving lives.

Learn more about how Verisys can assist your HCOs in meeting all government and regulatory standards.

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