5/1/2020 The MYTH of checking ALL State Medicaid sanction lists.

“Do I really need to check all the available state databases for sanctions?”

We get this question from time to time and it typically comes up when someone has heard about a possible software or cloud based solution. Software companies like to throw in as many databases as possible to gain perceived value. It is unfortunate since there is no reason to do so and it creates a significant waste of time and resources with no true impact on being compliant.

First, there is nothing in the federal law or regulations that mandate hospitals or health care systems of any size perform checks against each available State database. Unfortunately, there are misunderstandings and even some companies that are playing off this to create a fear that is simply incorrect. So where did this come from?

In 2011, Section 6501 of the ACA required “…States to terminate any provider (individual or entity) that has been terminated (for cause) by Medicare or by another State.” [See bottom of page 1 of link] https://downloads.cms.gov/cmsgov/archived-downloads/CMCSBulletins/downloads/6501-Term.pdf.

Which led to The Myth: Hospitals and healthcare systems must check all state databases.

Fact: The law mandates that the State Medicaid Agencies have the responsibility for checking all available state databases, not hospitals or health care systems. The State Medicaid agencies then are to determine whether to exclude in their state any individual or entity listed in another state. Until your state or the federal government excludes any such individual or entity, your Medicare and Medicaid dollars are not at risk.

So what does the OIG say about this?

For Hospitals and Health Care Systems….Nothing. The last Special Bulletin from the OIG does get more specific about its requirements and recommendations https://oig.hhs.gov/exclusions/files/sab-05092013.pdf but there is no discussion anywhere about checking all state databases. Likewise, the OIG website does not make any mention of a requirement to also check State databases.

For CMS and States….Review and take action as warranted. “As of July 1, 2018, the Cures Act requires State contracts with managed care organizations (MCOs) to include a provision that providers who were terminated from Medicare, Medicaid, or CHIP cannot participate in their Medicaid managed care networks.” The OIG is further recommending that CMS “confirm that States do not continue to have terminated providers enrolled in their Medicaid programs” https://oig.hhs.gov/oei/reports/oei-03-19-00070.asp

Then what are the States saying? Not one of the States with currently available databases, requires as part of participation in their State’s Medicaid program, to have all state databases checked. None. See for yourself at your respective state/s https://sterlingresults.com/our-solution/#state-medicaid-lists. It is simply because this is not the responsibility of hospitals and health care facilities.

So why the Myth? Some exclusion checking companies have manipulated these federal government notifications to bait clients into believing that all available states must be checked every month for exclusions. This simply isn’t true and results in a significant waste of time and money.

Keep in mind, your interests are to protect your Federal Medicare dollars and the State Medicaid dollars within your state’s operation. If neither the federal authorities or your applicable state indicates that an individual or company is excluded, it has no financial impact on your organization. Until such time as an exclusion in another state is added to your applicable state of operation or the federal lists, payments should not be at risk. If and when any exclusions from another state does show up in your state or on the federal lists, we would notify you with our ongoing ContinueCheck® monthly screening. This is how we keep our clients compliant without additional and unnecessary costs.

So the OIG isn’t requiring it. The GSA (SAM) isn’t requiring it. Not one state is requiring it. So why are some people checking every state every month and who is really saying you should? Software companies, not authorities that can issue fines and penalties.

The only possible value of checking another state database besides your own would be PRIOR to hiring or contracting as part of a onetime background check if an individual was coming from another state or had licenses in other states. This might give heads-up that a person could be added to the Federal OIG LEIE or your State’s database down the road if the reasons for the listing in another State were agreed to by the OIG or your State. However, for your ongoing monitoring each month, it is simply a waste of time and money for everyone, except those selling The Myth.

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.