Payment Matters

October 13, 2011

Many State Medicaid Agencies Require Providers to Perform Monthly Exclusion Checks

By: Lisa D. Stevenson

Many State Medicaid Agencies are now requiring enrolled providers to perform monthly exclusion checks to determine if their employees or contractors are excluded from receiving payments from federal health care programs.

In an effort to strengthen the integrity of the Medicaid program and help States reduce improper payments to providers and suppliers, effective March 25, 2011, CMS implemented final regulations [PDF] that require State Medicaid Agencies to screen all providers, suppliers, and persons with ownership and/or controlling interests, by checking the Office of Inspector General List of Excluded Individuals and Entities (Exclusion List) and the General Services Administration’s Excluded Parties List System (EPLS). This screening is required upon initial enrollment and monthly thereafter for as long as that provider is enrolled in the Medicaid program. In the preamble discussion, CMS recommends that States “consider making this a requirement for all providers and contractors, including managed care contractors in their Medicaid programs and CHIP.” According to CMS, many State agencies already made it their policy to require enrolled providers to do monthly exclusion checks based on prior CMS guidance.

Accreditation of Advanced Diagnostic Imaging Suppliers Must Be Completed by January 1, 2012

By: Thomas W. Coons

If you are a supplier of advanced diagnostic imaging services (ADI) and have not yet become accredited, you should start that process now. As part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), Congress required that suppliers who furnish the technical component (TC) of ADI be accredited effective January 1, 2012. To implement this requirement, the Centers for Medicare and Medicaid Services (CMS) designated three organizations to perform the accreditation:

• The American College of Radiology;
• The Intersocietal Accreditation Commission; and
• The Joint Commission.

ADI procedures include MRIs, CTs, and nuclear imaging, including positron emission tomography. They do not include x-ray, ultrasound, and fluoroscopy procedures. Suppliers who must be accredited include, but are not limited to, physicians, non-physician practitioners, and independent diagnostic testing facilities (IDTFs). Accreditation is required, however, only for suppliers of ADI paid under the Medicare Physician Fee Schedule; it does not apply to ADI services furnished in the hospital outpatient setting.