When the CMS publically introduced the idea of a new list for preclusions back in 2018, a lot of questions were generated. Does it apply to us? Where can I find it? What does it mean?

The Good: In short, it’s an attempt to curb prescription providers, both individuals and companies (“bad actors” as they say), that are on the CMS radar for activity deemed detrimental to the best interests of the Medicare program. If you got on the list, you were getting a 3 month’s notice of pending claim rejections and all Medicare Part D Sponsors and MA plans needed to heed this notice. The idea is estimated to save millions of dollars and help protect the public regarding the over prescription of pain killers across the nation.

Not a bad idea out of the gate but then we lived with it for all of 2019. And that’s when the short comings became noticeable.

The Bad: The preclusion list at first glance appears like a mini OIG LEIE exclusion list. And in a way it sort of is. Similar data fields and similar names although different implications. Of the 900+ individuals listed by CMS as precluded, more than 50% are already excluded on the OIG LEIE. Shouldn’t Medicare Part D Sponsors and MA plans already be finding these “bad actors” as excluded anyway? Is duplication really necessary?

And then there’s the “Oops” of different dates of birth for the same person between the OIG LEIE and the Preclusion List. Literally. Check out listings (if you can, which we’ll discuss in a moment as “The Unfortunate” below) for N. Ahmad (LEIE has 1/13/1950 vs. Preclusion having 1/3/1950), F. Aliaga (LEIE has 2/5/1953 vs. Preclusion having 2/2/1953), K. Ball (LEIE has 11/12/1965 vs. Preclusion having 11/13/1965)…etc. and that’s just at the beginning of the alphabet. The only saving grace is that both lists have the same NPI, so hopefully proper resolution of any possible name matches can still occur.

The Unfortunate: A lot of confusion developed as to who needed to be monitoring this new preclusion list. Over time, it became clearer that if it was a requirement to your organization, you would be notified and could obtain login credentials. While the Federal OIG LEIE exclusion list directly applies to hospitals and the healthcare industry, the CMS preclusion list is really for a smaller targeted audience of Medicare Part D Sponsors and MA plans. The list wasn’t intended to be such a “secret”, but did create a common misunderstanding of who needs to know.

For more on the Centers for Medicare and Medicaid’s (CMS) Preclusion List, see the respective links.

As always, be careful who you put your trust in for your provider and employee ongoing exclusion monitoring. Have questions? Ask the experts on exclusion monitoring. John Sterling Associates, LLC.