CMS Licensure Requirements for Medicare and Medicaid Providers and Suppliers

Requirements

“Over the past several years, we have taken a number of steps to strengthen our ability to deny or revoke Medicare billing privileges when providers or suppliers do not have or do not maintain the applicable State licensure requirements for their provider or supplier type or profession… To ensure that only qualified providers and suppliers remain in the Medicare fee-for-service (FFS) program, we require that Medicare contractors review State licensing board data on a monthly basis to determine if providers and suppliers remain in compliance with State licensure requirements. Medicare billing privileges would be revoked for those providers and suppliers who do not report a final adverse action (for example, license revocation or suspension, felony conviction) within the applicable reporting period, as required in § 424.516(b) through (e).”(30 days) A Rule by the Centers for Medicare and Medicaid Services on 02/02/2011

Guidelines for health care providers to screen employees, contractors and vendors monthly against LEIE exclusion list.
April 8, 2016

OIG imposes large fines, monetary penalties and possible program exclusion upon providers that employ or enter into contracts with excluded persons or entities to provide items or services payable by Federal health care programs.
April 8, 2016

Items and Services that Excluded Parties May Be Furnishing Which Will Subject Their Employer or Contractor to Possible Civil Monetary Penalty (CMP) Liability
April 8, 2016

Medicare/Medicaid payments are prohibited to providers who furnish any items and services at the medical direction or on the prescription of an excluded person.
April 8, 2016

Providers are responsible to ensure that the ordering or prescribing physician is not excluded from participation in Medicare/Medicaid.
April 8, 2016

OIG recommends contractors be screened by providers or validate that the contractor is conducting proper screening on behalf of the provider to avoid liability.
April 8, 2016