CMS Announces New Exclusion Related Sanction: the Preclusion List

Aside from the United States Department of Health and Human Services Office of the Inspector General’s (OIG) Exclusion List for health care providers and entities, the Centers for Medicare and Medicaid Services (CMS) has recently established a new rule that created a Preclusion List for healthcare providers and entities as well. The new Preclusion List went into effect on April 1, 2019.

An individual or entity can find their name on the Preclusion List in two ways:

• If you “are currently revoked from Medicare, are under an active reenrollment 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
• You have “engaged in behavior for which CMS could have revoked the prescriber, 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 interest of the Medicare program. Such conduct includes, but are not limited to, felony convictions AND Office of Inspector General (OIG) exclusions. (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html) (https://www.exclusionscreening.com/cms-preclusion-list/)

A healthcare provider or entity that finds their name on the Preclusion List will be precluded from receiving payments for Medicare Advantage items and services or Medicare Part D drugs. Part D providers will be mandated to reject prescriptions from any individual or entity that is on this list, and Medicare Advantage plans will be mandated to deny such payments. In contrast to the OIG’s Exclusion List, the Preclusion List is not accessible to the public, and therefore cannot be checked periodically by providers. Any provider or entity that is put on the Preclusion List will receive individual notice of the determination.

For more information concerning the CMS Preclusion List, please contact David R. Ross Esq. at (518) 462-5601 or via e-mail at dross@oalaw.com. Samantha L. Femia, Law Clerk, wrote this article.