Medicare Advantage Provider Exclusions Monitoring
The Centers for Medicare and Medicaid Services (CMS) require contractors and their First Tier Downstream and Related entities (FDRs) to monitor federal exclusions lists. The parties/entities on these lists are excluded from various activities, including rendering services to Medicare enrollees (unless in the case of an emergency, 42 CFR § 1001.1901) and from being employed or contracted to render services to Medicare enrollees. Health Net requires that its participating physician groups (PPGs), hospitals, ancillary providers, and physicians continuously monitor federal exclusion lists. The information below provides the names of each federal exclusion list, governing regulations and CMS guidance, including links to publically available exclusion lists.
HEALTH NET AND FDR HIRING AND CONTRACING RESPONSIBILITIES
Health Net and their First Tier Downstream and Related entities (FDRs) are required to monitor federal exclusion lists to ensure that Health Net and their First Tier Downstream and Related entities (FDRs) are not hiring, contracting or paying excluded parties or entities for services rendered to enrollees in Health Net’s MA and MA-PD plans. MAOs and their FDRs must check the List of Excluded Individuals and Entities (LEIE) and Exclusions Extract Data Package (EEDP) federal exclusion lists prior to hiring or contracting with any new employee, temporary employee, volunteer, consultant, governing body member, or FDR for Part C- and Part D related activities. MAOs and their FDRs must continuously monitor these lists at least monthly to ensure parties or entities that were previously screened have not become excluded later.
List of Excluded Individuals and Entities (LEIE)
The Office of the Inspector General -- Health and Human Services, (OIG-HHS) imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act.
Exclusions Extract Data Package (EEDP)
The General Services Administration (GSA’s) EEDP is a government-wide compilation of various federal agency
exclusions, and replaces the Excluded Parties List System (EPLS). Exclusions contained in the EEDP are governed by
each agency’s regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion
databases. All parties or entities listed on the EEDP are subject to exclusion from Medicare participation.
- The current EEDP is available on the SAM website at: www.sam.gov, with additional information located
under Help > User Guides > Quick User Guides > Helpful Hints for Public Users.
HEALTH NET AND FDR PAYMENT RESPONSIBILITIES
Health Net and their First Tier Downstream and Related entities (FDRs): PPGs, hospitals, and ancillary providers
cannot pay participating and non-participating parties or entities included on these lists for any services using
federal funds, except as documented in the CMS Internet Only Manual, publication 100-16, Chapter 6 --
Relationships with Providers, which states, ‘‘The OIG has a limited exception that permits payment for emergency
services provided by excluded providers under certain circumstances. See 42 CFR § 1001.1901.’’ FDRs contracting
with Health Net and their First Tier Downstream and Related entities (FDRs) must have a documented process in
place to ensure compliance with these guidelines, and notify enrollees who obtain services from excluded parties
and make claims payments as allowed under these exceptions. This documentation is subject to audit upon
request from Health Net or CMS.
GOVERNING REGULATION AND CMS GUIDANCE
The names of parties that have been excluded from Medicare participation are published in the Office of the
Inspector General U.S. Department of Health and Human Services (OIGHHS) List of Excluded Individuals and Entities
(LEIE), and on the General Services Administration’s (GSA) Exclusions Extract Data Package (EEDP) (or Excluded
Parties List System (EPLS), which was replaced by the EEDP), as referenced through the System for Award
Management (SAM) website at ww.sam.gov. Medicare Advantage organizations (MAOs) and their FDRs must
abide by the regulations documented in the Social Security Act 1862(e)(1)(B), 42 CFR §422.503(b)(4)(vi)(F),
422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6), and 1001.1901. These federal exclusion requirements are further
interpreted and communicated as guidance by CMS in Medicare Manual, Volume 100-16, Chapters 9 and 21
§50.6.8. Additional regulations that require sponsors to include CMS requirements in their contracts,
as well as monitor their FDRs, are available in 42 CFR §422.504(i)(4)(B)(v) and 423.505(i)(3)(v).