These examples illustrate the diverse grounds for exclusions and the concomitant difficulty a health care provider may encounter in discovering that it employs or contracts with an excluded party
How Can Excluded Individuals and Entities Affect You
You should not employ or contract with excluded individuals and entities, since they are prohibited from participating in federal health care programs, and doing so violates Medicare and Medicaid provider agreements. In addition, you cannot submit claims for any items or services furnished by excluded individuals and entities to federal health care programs.
This prohibition applies to all methods of federal health care program reimbursement, including fee for service claims, prospective payment system (PPS) payments, and the submission of costs on Medicare and Medicaid cost reports. Moreover, the prohibition extends beyond direct patient care services to include administrative, clerical, and management services. Any individual or entity submitting claims or reporting costs to any federal health care program has an affirmative duty to ensure that all employees and contractors providing services encompassed in those claims or costs are not excluded.
What Can You Do?
Although anyone who submits claims to federal health care programs is at risk of mistakenly billing for services or supplies furnished by excluded individuals or entities, there are steps that you can take to mitigate this risk: