Why it’s Important to Understand Medicare and Medicaid Exclusions and Preclusions

In the post-public health emergency (PHE) era, I have noticed what I think may be a glitch in the computer system at the Centers for Medicare & Medicaid Services (CMS). Maybe I’m wrong. Let me give you the facts, and you can decide whether it’s a glitch, human error, or a conspiracy against Medicare and Medicaid providers.

Regardless of the reason, it is imperative for physicians to stay abreast of their Medicare and Medicaid privileges. Make a monthly check to see if you’ve been erroneously terminated without your knowledge. Can that really happen, you ask? Being terminated without your knowledge legally should not happen, and you have recourse. But it can happen – and has.

The first instance of this tomfoolery occurred about 3-4 years ago. My client was an internist working in North Carolina and Virginia. North Carolina Medicaid terminated him erroneously; I cannot even remember the reason, but it was wrong. Dr. Doe hired me to get him reinstated, which we promptly did. In the meantime, CMS’s computer system picked up that Dr. Doe had been terminated from North Carolina Medicaid and terminated his Medicare privileges. Dr. Doe had to hire us again for a second erroneous termination. The cycle continued one more time, both in North Carolina and Virginia. He was terminated from Medicaid and Medicare again, and we worked to get him reinstated again.

It turns out that CMS updates its preclusion list every 30 days. Depending on when your state updates its preclusion list, a doctor could be reinstated with Medicare on, say, Sept. 18, 2023. If his or her state Medicaid department checks for Medicare privileges anytime from Sept. 18-30, they would be listed as having no Medicare privileges until CMS updates the program.

Being terminated from Medicare is a quick way to get terminated from Medicaid. You need a lawyer to work both Medicare and the Medicaid angles concurrently. The reason that this is so important is that if a hospital has a physician performing services without Medicare or Medicaid privileges, the hospital then owes an overpayment and will be forced to temporarily fire or suspend the doctor until he is reinstated.

Since that incident, which occurred at the beginning of COVID, about three years ago, 6-7 more almost identical incidents have happened. But not in North Carolina – in Texas, Illinois, New York, Florida, South Carolina, and Nebraska.

So, I started wondering whether there was a large-scale problem with how states and CMS communicate about exclusions. Dr. Doe’s frustrating, cyclical, erroneous terminations from Medicare and Medicaid could be systemic.

The next doctor had been terminated correctly many years ago for an infraction, which he readily admits. He did his penance and paid his dues for his crime. He was back to work as an ER surgeon, and from what I understand, he is excellent at his job, which happens to be in a rural area. Medicare picked up on his infraction four years after he paid for his mistake. Medicare terminated him because he didn’t volunteer his infraction to Medicare.

We all know that failing to volunteer infractions to CMS will get you terminated (or a loss of your privileges). This doctor is a trauma surgeon. In my humble opinion, ER surgeons are the renaissance men or women of the medical world. As I am sure is the case with most ER surgeons, this doctor never filled out his own Medicare and Medicaid re-credentials; someone employed by the hospital always filled out his applications. Ever since he restarted his career, understandably, he did not want to broadcast his infraction. Of course, the management of the rural hospital had actual knowledge of the infraction, but somewhere through the “telephone call game,” employees lower down the totem pole were not informed. So, his Medicare application was submitted with an error that the doctor did not catch. Once the billing department learned of his revoked Medicare privileges, he was suspended without pay.

However, in this case, we approached the situation from two angles; we sought resolution for both Medicare and Medicaid concurrently, because we did not want another cyclical issue.