Sanctions, Exclusions, Terminations, Suspensions, and Debarment are administrative actions taken against an individual or entity for reasons that include fraud, integrity, or quality.
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), has the authority to impose administrative and disciplinary actions, including imposing Civil Monetary Penalties.
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 prohibited from participating in any Federal Healthcare Reimbursement Programs, including Medicaid, CHIP, and Medicare, regardless of the enforcing authority.
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?
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 for noncompliance. In that case, this does not qualify as voluntary action.
Do “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 that prevents 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 Medicaid, CHIP, or Medicare.
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 their government healthcare programs from providers who pose an increased risk.
What is the duration of 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 a three-year exclusion, all other States should impose at least the same three-year period; however, States may 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 the same limitations on termination as those 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.
Search HealthProviders DB
HealthProviders DB profiles include all Federal & State Exclusions, Terminations, Suspensions, Sanctions, and Debarments Lists, as Exact or Possible matches, greatly simplifying your exclusion screening.
Exclusions that match by NPI number, or by full name and address, are “Exact” matches.
Exclusions are imported monthly as they become available, keeping the database up to date.
An individual or organization whose billing privileges have been revoked by the OIG or any State cannot participate in Medicaid, Medicare, or the Children’s Health Insurance Program (CHIP).
Learn more about who needs to be screened.
OIG Exclusions and SAM Debarments – Why both?
Enter an NPI number, license number, or provider name in the search field below to search the Exclusions.
Alternatively, you can also search the Providers.
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Select a State to view the list of Exclusions by State.
Additionally, you can narrow the list by city, among other options, from the Filter Panel, which you can open by clicking the vertical ellipses ⋮ in the upper right corner of the app.
Use HealthProviders DB Batch Exclusion Screening and Exclusion-monitoring Solutions to avoid potential Civil Monetary Penalties.