What You Need to Know About CMS Preclusion List

January 17, 2023

CMS announced a significant change in its operations in April 2018, which barred problematic prescribers from receiving payment for Part D prescriptions. According to their estimates, the initiative will result in more than $34 billion in savings by the end of 2019. 

CMS enacted the rule on April 1, 2019, after they had released their new Preclusion list earlier that year. In addition to reducing the CMS's budget, the Preclusion list aimed to improve healthcare across the State by eliminating unethical or problematic providers.

At the end of this article, you will find everything you need to know about the CMS Preclusion List.

What Is the CMS Preclusion List? 

The Preclusion List is generated and updated by the CMS containing prescribers and providers who cannot receive payment for prescribed Part D drugs or rendered Medicare Advantage (MA) services. 

The List identifies providers and prescribers by their Tax Identification Number (TIN) level. The revoked or inactive designation on Medicare enrollments must appear in their TIN for individuals or entities to appear on the Preclusion List. 

The List is made available to Part D payer plans and Medicare Advantage. The claim will not be paid whenever Medicare Advantage receives a claim for a healthcare service rendered by a precluded provider or entity. 

Also, if a Part D payer receives reimbursement claims from a pharmacy or Medicare beneficiary on a prescribed drug by a precluded prescriber, the CMS will void such claims. 

Why was the Preclusion List Created?

According to the Federal Register Rules and Regulations update as of April 2018, 3 main reasons justified the creation of the CMS Preclusion List;

  •  To replace Medicare Advantages (MA) requirements for enrollment.
  •  Relieving the burdens on Medical Advantage and Part D providers while maintaining the program integrity. 
  •  Ensure that defaulting/problematic prescribers do not receive payment for prescribing Part D drugs. 

How CMS Preclusion List Affects Providers and Organization

Your healthcare organization must be compliant with the CMS Preclusion Rule. By unknowingly hiring precluded providers into your facility, you potentially put your patients at risk. 

Getting reimbursements for services by providers on the Medicare Preclusion List is impossible as the claims will be rejected. 

Frequently rejected claims can adversely affect your revenue cycle. Moreover, non-compliance with the CMS Preclusion list can also create financial problems for your organization. 

You can easily avoid this mistake by conducting regular checks against the Provider List. The Preclusion List is maintained and updated monthly, which is also how frequently you should perform the screening exercise. 

How Does a Provider or Entity End up on the Preclusion List?

Providers or entities that are on the Preclusion List are either revocation-based or Conduct/Behavior-based. 

Revocation Based Preclusion

In this category, providers or entities might be placed on the Preclusion List if; 

  •  They are under an active re-enrollment bar and 
  •  CMS has investigated the underlying events that led to the revocation and finds it detrimental to the Medicare program's best interest. The CMS will critically examine the conduct leading to their cancellation during the investigation. CMS will also consider the effect of the individual or entity's behavior on the integrity of the MA or Part D program. 

The CMS might place the care prescriber, provider, or supplier on the Preclusion List when they meet these revocation requirements. 

Conduct/Behavior-Based Preclusion

The CMS might preclude individuals or entities based on conduct if; 

  • The individual/entity has engaged in conducts or behaviors that would have led to a revocation of their Medicare enrollment privileges and;
  •  CMS determines that the individual or entities behaviors that led to the cancellation of the privileges go against the Medicare program's core values and integrity.  

How Would an Individual or Entity Know if They are Included in the CMS Preclusion List?

While the Medicare Preclusion List is not accessible to the general public, the CMS directly notifies providers and entities by; Sending an email, then a letter to the provider. The email and letter will detail the date and reason for preclusion and rights to appeal.

The email and letter are then forwarded to the provider's National Plan and Provider Enumeration System (NPPES) address or provider's Provider Enrollment Chain and Ownership System (PECOS) address. 

Is the CMS Preclusion List Similar to the OIG's Exclusion List? 

Some providers might appear on both lists. But the CMS Preclusion list differs from the OIG List of Excluded Individuals and Entities. Therefore, your organization should screen providers against both lists. 

The OIG Exclusion List is a database of individuals and entities excluded from partaking in Federal and State health programs. Depending on the nature of the underlying action, the exclusion is either permissive or mandatory. 

While the CMS Preclusion list is a database of all providers, prescribers and suppliers precluded from getting reimbursement for Part D drugs or Medical Advantage Items prescribed or provided to a Medicare beneficiary. 

The OIG exclusion list will be publicly accessible online and on the 41 State Medicaid exclusion database instead of the CMS Preclusion list, only available to Part C and Part D payer plans. It is easier to screen your providers against the OIGs Exclusion List than the OIGs Preclusion List. 

What are the Duration Individuals and Entities Stays on the Preclusion List? 

If for any reason an individual/ entity exhausts their first level of appeal, CMS will add their name to the Preclusion List. 

However, suppose the preclusion action occurred because the OIG excluded the party involved from the Federal and State programs. In that case, the individual or entity is excluded effectively from the exclusion date. 

The duration an individual or entity will remain on the preclusion list largely depends on the circumstance around which they ended up on the List in the first place. 

For Instance, if the preclusion was due to an exclusion action, the individual or entity will remain precluded until the OIG reinstates them. 

Also, If the preclusion was due to a revocation action, the party will remain actively precluded for the length of their re-enrollment bar. The re-enrollment bar can be active between 1 to 3 years, depending on the seriousness of the reason for revocation.

Finally, If a preclusion action is due on a felony conviction, the preclusion will be in effect for ten years beginning on the date the verdict took effect. However, CMS can determine if a shorter time is warranted. 

Latest articles.

Article headline