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

Requirements

“Set forth below is a listing of some of the types of items or services that are reimbursed by Federal health care programs which, when provided by excluded parties, violate an OIG exclusion. These examples also demonstrate the kinds of items and services that excluded parties may be furnishing which will subject their employer or contractor to possible CMP liability.

Services performed by excluded nurses, technicians or other excluded individuals who work for a hospital, nursing home, home health agency or physician practice, where such services are related to administrative duties, preparation of surgical trays or review of treatment plans if such services are reimbursed directly or indirectly (such as through a PPS or a bundled payment) by a Federal health care program, even if the individuals do not furnish direct care to Federal program beneficiaries;
Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling prescriptions for drugs reimbursed, directly or indirectly, by any Federal health care program;
Services performed by excluded ambulance drivers, dispatchers and other employees involved in providing transportation reimbursed by a Federal health care program, to hospital patients or nursing home residents;
Services performed for program beneficiaries by excluded individuals who sell, deliver or refill orders for medical devices or equipment being reimbursed by a Federal health care program;
Services performed by excluded social workers who are employed by health care entities to provide services to Federal program beneficiaries, and whose services are reimbursed, directly or indirectly, by a Federal health care program;
Administrative services, including the processing of claims for payment, performed for a Medicare intermediary or carrier, or a Medicaid fiscal agent, by an excluded individual;
Services performed by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer that are related to and reimbursed, directly or indirectly, by a Federal health care program;
Items or services provided to a program beneficiary by an excluded individual who works for an entity that has a contractual agreement with, and is paid by, a Federal health care program; and
Items or equipment sold by an excluded manufacturer or supplier, used in the care or treatment of beneficiaries and reimbursed, directly or indirectly, by a Federal health care program.” OIG Special Advisory Bulletin: The Effect of Exclusion From Participation in Federal Health Care Programs (September, 1999)

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

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

CMS Licensure Requirements for Medicare and Medicaid Providers and Suppliers
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