Sanctions, Exclusions, Terminations, Suspensions, and Debarment are administrative actions taken against an individual or entity by the Office of Inspector General (OIG), State Healthcare Program Agencies, the Medicaid Fraud Control Unit (MFCU), or one of the many agencies associated with the General Services Administration (GSA), for reasons that include fraud, integrity, or quality.
For healthcare organizations, an individual or entity that is sanctioned or excluded by the OIG, terminated by a State Healthcare Program authority, or suspended or debarred by the GSA is prevented from participating in any Federal Healthcare Reimbursement Program, including Medicaid, CHIP, and Medicare programs, regardless of the enforcing authority.
Healthcare organizations must screen new hires, current employees, and vendors to prevent potential Civil Monetary Penalties (CMP).
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Federal database check regulations
The Federal Database Checks regulations — 42 CFR Part §455.436 mandate that State Medicaid Agencies must:
(a) Confirm the identity and determine the exclusion status of providers and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of Federal databases.
(b) Check the Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and any such other databases as the Secretary may prescribe.
(c)(1) Consult appropriate databases to confirm identity upon enrollment and re-enrollment; and
(c)(2) Check the LEIE and SAM no less frequently than monthly.
Who needs to be screened?
Healthcare organizations must screen new hires and regularly monitor current employees, as well as the individuals and entities with whom they do business, to avoid potential Civil Monetary Penalties.
This includes doctors, nurses, pharmacists, and other healthcare professionals interacting with patients and federal healthcare programs, such as Medicare or Medicaid.
Even if someone isn’t directly providing care, they might still be involved in billing, patient records, or managing payments from federal programs. These roles are critical, and OIG exclusion checks should apply here.
Think of anyone supplying medical equipment, pharmaceuticals, or services to a healthcare organization. Just because someone isn’t a full-time employee doesn’t mean they shouldn’t be checked. They must pass an OIG background check if they provide goods or services involving federal funds.
Volunteers can be involved in patient care or sensitive healthcare operations in specific settings. While not always required, screening volunteers can help ensure the organization maintains compliance with federal regulations.
What does “termination” mean?
The Centers for Medicare & Medicaid Services (CMS) defines “termination” as the action taken by a State Medicaid program, CHIP, or the Medicare program that revokes a provider’s or supplier’s billing privileges “for cause.”
What does “for cause” mean for Medicaid and CHIP providers?
Termination “for cause” may include, but is not limited to, reasons based on fraud, integrity, or inadequate quality.
“For cause” does not include cases where a State terminates a Medicaid or CHIP provider due to inactivity and for failure to submit claims.
“For cause” also does not include voluntary action the provider takes to end their participation in the program, except where that “voluntary” action is taken to avoid sanction.
For example, suppose a provider submits a request to the State to “voluntarily” terminate its provider agreement to avoid sanctions due to non-compliance. In that case, this does not qualify as voluntary action.
Do the terms “termination” and “exclusion” mean the same thing?
No, but effectively yes.
Termination is not the same as exclusion. However, if your Medicaid billing privileges are terminated, it effectively excludes you from the Medicaid program.
An exclusion is a penalty imposed by the Office of Inspector General (OIG) on providers and suppliers, preventing them from participating in federal healthcare programs, including Medicaid, CHIP, and Medicare, for violating federal law.
Individuals and entities may be excluded from participating in federal healthcare programs for misconduct ranging from fraud convictions to patient abuse to defaulting on health education loans.
For the most part, an “exclusion” is a penalty imposed by the OIG for violation of federal law, whereas a “termination” is the loss of billing privileges imposed by the State.
Effectively, both result in the provider’s involuntary removal from the Medicaid program, CHIP, or Medicare programs.
What are the timeframes for States reporting provider terminations?
There is no specified timeframe for reporting terminations. However, States should report terminations monthly to assist other States in protecting themselves from providers who pose an increased risk to government healthcare programs.
What is the duration of State provider terminations?
Section 6501 of the Affordable Care Act requires each State Medicaid program to terminate any provider who has been excluded from Medicaid, CHIP, or Medicare by another State Medicaid program.
The exclusion period is at least as long as the termination period imposed by the initial terminating State.
For example, if the initial terminating State imposes exclusion for three years, all other States should impose at least the same three-year duration; however, States can impose more extended periods.
In other words, each State should adhere to its laws concerning the duration “after” the duration imposed by the initial terminating State.
Are there exceptions to terminating a provider?
Yes.
The statute provides for the same limitations on termination that apply to exclusion under 1128(c)(3)(B) and 1128(d)(3)(B) of the Social Security Act.
Thus, a State may request a waiver of the requirement to terminate a particular provider’s participation. State agencies may submit such waiver requests to their respective CMS Regional Offices.