CurrentprominencehealthfirstoffloridaPolicy COMP.COMM.001

OIG/GSA Exclusion and CMS Preclusion List Screening

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Policy requiring screening of staff, contractors, vendors, volunteers, consultants, providers and related entities against OIG LEIE, GSA/SAM exclusions, and the CMS Preclusion List at hiring/contracting and monthly thereafter; applies to all persons affiliated with Prominence Health Plan.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyOIG/GSA Exclusion and CMS Preclusion List Screening

Policy CodePolicy COMP.COMM.001

Change TypeNo material change

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

Key ActionIf a claim was submitted for services by an excluded or precluded provider, investigate, recoup ineligible payments, delete PDE data if needed, and report to NBI MEDIC.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyfrequency of ongoing screenings

prior to hire/contractrequired pre-hire/contract screening

Allpolicy applies to

requiredrecoupment

Exclusion and Preclusion Screening Requirements

Exclusion/Preclusion Screening Criteria and Actions

Screening requirements and actions when matches are found.

Perform exclusion screening (OIG LEIE, SAM/SAM exclusions including SDN, CMS Preclusion List) prior to hiring/contracting new employees, temporary employees, volunteers, interns, consultants, governing body members, FDRs, and providers.

Perform monthly re-checks of applicable sanction/exclusion lists for staff, vendors, volunteers, consultants and providers (the Preclusion List must be checked prior to contracting a provider and monthly thereafter).

Vendors must: review applicable sanction lists prior to hiring/contracting and monthly thereafter; promptly notify the Prominence Health Plan Compliance Officer of any apparent matches; immediately remove excluded staff/entities from duties related to Prominence Health Plan; and maintain documentation of all screenings.

If a potential match is discovered, notify the Compliance Officer who will initiate an investigation; staff with potential matches may be placed on leave until the investigation is complete.

Prominence Health Plan will not employ or contract with any staff or entity known to be excluded from participation in federal health care programs.

If a confirmed exclusion/preclusion affects billed services or prescription drug events (PDEs): investigate claims to determine scope, recoup ineligible payments as required, delete PDE data if applicable, and report the incident to NBI MEDIC.

Actions When Excluded or Precluded Providers Are Identified

Denial Risk

Investigate, recoup payments, delete PDEs, and report NBI MEDIC for claims involving excluded/precluded providers

If Prominence Health Plan discovers that a claim was submitted for services or drugs prescribed or delivered by an excluded or precluded provider, the plan must investigate the matter, determine if other claims were submitted by the excluded provider, recoup ineligible payments, delete Prescription Drug Event (PDE) data as appropriate, and report the incident to NBI MEDIC.

Investigate to determine whether additional claims were submitted by the excluded/precluded provider.
Recoup any ineligible payments associated with services or drugs furnished by the excluded/precluded provider.
Delete PDE data if the claim involves a prescription drug event linked to the excluded/precluded provider.
Report the incident to NBI MEDIC.

Defined Terms Used in This Policy

CMS — Centers for Medicare and Medicaid Services definition

DefinitionCenters for Medicare and Medicaid Services (CMS): The federal agency that runs the Medicare program and works to ensure beneficiaries receive high-quality health care.

Scope of CMS Preclusion ListPreclusion List: a CMS-compiled list of individuals and entities currently revoked from Medicare and under a reenrollment bar (see 42 C.F.R. references).

ReferenceWebsite: https://cms.gov (as cited in policy).

Delegated Entity — definition of any party that enters into an agreement with a QHP issuer

DefinitionDelegated Entity: Any party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals, employers, employees, and their dependents (45 C.F.R. 156.20).

ExamplesMay include agents, brokers, or other organizations performing administrative or healthcare functions for a QHP issuer.

Contract TimingMust be screened against sanction lists prior to hiring/contracting and monthly thereafter per policy requirements.

First-Tier Entity / Downstream Entity — parties entering written arrangements with MA or Part D sponsors

First-Tier EntityAny party that enters into a written arrangement, acceptable to CMS, with the MA organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare-eligible individual (42 C.F.R. 422.2, 423.4).

Downstream EntityAny party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA organization or Part D benefit below the level of the arrangement between the MA organization or Part D plan sponsor and a first-tier entity; includes arrangements down to the ultimate provider of health and administrative services (42 C.F.R. 422.2, 423.4).

Related EntityEntities related to MA and/or Part D sponsors by common ownership or control (policy references CMS definitions).

OIG / Preclusion List — definition of HHS OIG exclusion authority and CMS Preclusion List

OIG RoleOffice of Inspector General (OIG): The HHS department tasked with enforcement of waste, fraud, and abuse efforts in Medicare, Medicaid and other HHS programs; authorized to exclude individuals and entities from participation in Federal health care programs.

Preclusion ListPreclusion List: a CMS-compiled list of individuals and entities currently revoked from Medicare and under a reenrollment bar (Preclusion List must be checked prior to contracting a provider and monthly thereafter).

Reasons for Exclusion/PreclusionReasons include convictions of program-related crimes, patient abuse, health care fraud, controlled substances abuse, and license revocation or suspension.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyOIG/GSA Exclusion and CMS Preclusion List Screening

Policy CodePolicy COMP.COMM.001

Change TypeNo material change

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

Key ActionIf a claim was submitted for services by an excluded or precluded provider, investigate, recoup ineligible payments, delete PDE data if needed, and report to NBI MEDIC.

SourceLink

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OIG/GSA Exclusion and CMS Preclusion List Screening

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Exclusion and Preclusion Screening Requirements

Exclusion/Preclusion Screening Criteria and Actions

Screening requirements and actions when matches are found.

If a potential match is discovered, notify the Compliance Officer who will initiate an investigation; staff with potential matches may be placed on leave until the investigation is complete.

Prominence Health Plan will not employ or contract with any staff or entity known to be excluded from participation in federal health care programs.

Actions When Excluded or Precluded Providers Are Identified

Denial Risk

Investigate, recoup payments, delete PDEs, and report NBI MEDIC for claims involving excluded/precluded providers

Investigate to determine whether additional claims were submitted by the excluded/precluded provider.
Recoup any ineligible payments associated with services or drugs furnished by the excluded/precluded provider.
Delete PDE data if the claim involves a prescription drug event linked to the excluded/precluded provider.
Report the incident to NBI MEDIC.

Defined Terms Used in This Policy

CMS — Centers for Medicare and Medicaid Services definition

DefinitionCenters for Medicare and Medicaid Services (CMS): The federal agency that runs the Medicare program and works to ensure beneficiaries receive high-quality health care.

Scope of CMS Preclusion ListPreclusion List: a CMS-compiled list of individuals and entities currently revoked from Medicare and under a reenrollment bar (see 42 C.F.R. references).

ReferenceWebsite: https://cms.gov (as cited in policy).

Delegated Entity — definition of any party that enters into an agreement with a QHP issuer

ExamplesMay include agents, brokers, or other organizations performing administrative or healthcare functions for a QHP issuer.

Contract TimingMust be screened against sanction lists prior to hiring/contracting and monthly thereafter per policy requirements.

First-Tier Entity / Downstream Entity — parties entering written arrangements with MA or Part D sponsors

Related EntityEntities related to MA and/or Part D sponsors by common ownership or control (policy references CMS definitions).

OIG / Preclusion List — definition of HHS OIG exclusion authority and CMS Preclusion List

Reasons for Exclusion/PreclusionReasons include convictions of program-related crimes, patient abuse, health care fraud, controlled substances abuse, and license revocation or suspension.