Preclusion List

Posted on

                                         What is a Preclusion List?                                                                                                                         

It is a listing that is generated by Centers for Medicare & Medicaid Services (CMS).  It contains a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services of Part D drugs furnished or prescribed to Medicare beneficiaries.  The list was created to ensure patient protections and safety and to protect the governmental funds from providers and prescribers that have been identified as wrongdoers.  The list was also created to replace the Medicare Advantage and prescriber enrollment requirements.  Although this list has some overlap to the Office of Inspector General’s (OIG) Exclusion List, the Preclusion List is not the same as the Exclusion List.

How does an individual or entity get on the Preclusion List?

There are two ways that someone can become part of the list: (1) If he/she is currently revoked from Medicare, are under an active re-enrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interest of the Medicare Program; (2) if he/she has engaged in behavior for which CMS could have revoked him/her as an individual or entity to the extent applicable if he/she 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.  Interestingly, though, the Preclusion List is not applicable to Medicaid.

How will you know if you are on the Preclusion List?

Unlike the Exclusion List, the Preclusion List is extremely restricted and not shared publicly.  Only CMS-approved healthcare plans, with a valid Health Plan ID, can gain access to the Preclusion List.

The notification will come by an email and a letter from CMS or the Medicare Administrative Contractor (MAC) in advance of your inclusion on the Preclusion List.  The email and letter will be sent to your Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing.  The letter will give you the reason you are being precluded, the effective date of your preclusion, and your applicable rights to appeal and challenge the CMS placement.  Providers are not added to the list until they have exhausted their first level of appeal.  Therefore, if the first level of appeal is found favorable, the provider would not be included on the list.

Length of time you are on the Preclusion List

A provider will be precluded for the length of their re-enrollment bar if they are currently revoked or would have been revoked had they enrolled in the Medicare program.  The re-enrollment bar is a minimum of 1 year to 3 years depending on the severity of the basis for the revocation.  A provider placed on the Preclusion List because of a felony conviction will remain on the Preclusion List for a 10-year period, beginning on the date of the felony conviction, unless CMS determines that a shorter length of time is warranted.

Impacted providers will not drop off the Preclusion List.  Instead, the list will indicate a reinstatement date that an impacted provider is no longer precluded.  Additionally, a provider with multiple preclusion events will appear as separate line items on the file with separate effective dates and end dates; the dates will not overlap.  It is possible that a provider may be reinstated back to the exclusion date on the file if the outcome of the provider’s subsequent appeal is favorable.  This would then remove any period of preclusion for the provider, making it possible for the provider to resubmit any claims denied.

What to do if you get a notification?

If you receive a notification from CMS or your MAC, we highly recommend that you contact a healthcare attorney (we recommend Liles Parker) as quickly as you can to rectify the situation.

Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities.  We place great importance in being compliant with governmental regulations.   Contact us to learn more about how we can help you gain more revenue within the scope of compliance.

Leave a Reply

Your email address will not be published. Required fields are marked *