Before the ubiquity of email, checking the mailbox each day was kind of fun. Maybe a letter from a loved one, a card from a long-lost-friend, or a big refund check from the government. Nowadays, email seems to have made snail mail obsolete if not annoying. AND, with so much email and many managing more than one personal/professional address, it can seem like a perpetual burden.

Certain communications cannot be missed. The IRS has strict response deadlines as does other government programs like the Centers for Medicare and Medicaid Services, i.e., CMS. Mail from CMS requiring action must be addressed promptly. Not responding can have dire, costly consequences.

In our blog we have discussed the Medicare Exclusion list. This is the list of providers literally excluded from participation and receiving payment from ANY government payer. However, we have never discussed the Preclusion list and thought it worth discussing.

Medicare Advantage Plans (MA plans) are Medicare Part C plans are what many refer to as Medicare “replacement” plans. The term replacement is used because unlike a supplemental plan which makes a secondary payment after Medicare initially adjudicates a claim, MA plans receive premium payments from CMS to cover the totality of liabilities for beneficiaries. In other words, the MA plan pays for ALL healthcare services and CMS/Medicare (or really the Medicare Administrative Contract or MAC) pay nothing.

The Preclusion list is “a list of providers and prescribers... precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries.” “ CMS publishes the Preclusion List by the 25th of each month or the last Monday of the month, whichever is earlier, for the following month. ”

Paraphrasing a CMS URL, the Preclusion list was created in 2019 to replace the MA and prescriber enrollment requirements while ensuring patient protections and safety. Further it was implemented to protect the Trust Funds (Medicare money) from prescribers and providers identified as bad actors. Stated otherwise, it was created to hold MA plans and Part D (Medicare prescription drug) providers accountable regarding non-payment of claims for providers who may eventually find their way on to the Exclusion list.

Who is on the list? Any person or entity:

• Currently revoked from Medicare, under active reenrollment bar, & CMS believes underlying conduct detrimental to the best interests of the Program.

• Engaged in behavior for which CMS could have revoked status & underlying conduct, detrimental to the best interests of the Program.

• Convicted of a federal/state felony within the previous 10 years.

Why do you need to know this? If you employ a licensed professional... (in HRSA-speak both LIPS and OLCPs) and a notice is received regarding the preclusion list, you have 60 days to appeal. Fail to get this resolved and straight Medicare as well as MA related services will be denied leaving patients holding the financial bag. Not only will claims for direct care go unpaid but so also will any prescriptions, DME, diagnostics, external care modalities, etc. It is bad news.

What do you need to do? Update addresses for Provider Enrollment Chain and Ownership System (PECOS) address and National Plan and Provider Enumeration System (NPPES) mailing address. For ALL LIPs and OLCPs. Make the primary address the health center’s corporate address and/or require employed staff to submit communication from PECOS/NPPES to HR, the Compliance Officer, and/or the Medical Director. The communication regarding preclusion will include the reason for preclusion, the effective date, and applicable rights to appeal. Rapid response is required before non-payment penalties and disallowance of referrals are imposed.

Like most items pertaining to credentialing and provider enrollment, this is tedious, time-consuming, and administratively burdensome. However, advanced planning and diligent tracking of necessary items mitigates risk.

If your health center has a rock-solid credentialing and enrollment process in place, celebrate! Good for you. If you don’t, find an external resource to elevate compliance. Contact the team at PMG Credentialing to see how we might help. You will be glad you did.