Medicare/Medicaid Sanctions

Question 1

The Joint Commission
Medicare/Medicaid Sanctions

Answer 1

Not specifically addressed

Question 2

NCQA Health Plan
Medicare/Medicaid Sanctions

Answer 2

Verification of Medicare/Medicaid sanctions may be done through a query of one of the following
- OIG List of Excluded Individuals and Entities (LEIE)
- Medicare Exclusions Database
- NPDB
- AMA Physician Master file
- FSMB
- State Medicaid agency or intermediary
- Medicare intermediary
- Federal Employees Health Benefits Plan (FEHB) Program department record published by the Office of Personnel Management, Office of Inspector General
Time limit: must be verified within 180 days (MCO)/120 days (CVO) of the credentialing decision

Question 3

ACHC Acute Care Hospitals
Medicare/Medicaid Sanctions

Answer 3

Sanctions or disciplinary actions take by healthcare facilities, specialty boards, federal agencies, malpractice carriers must be reviewed for each applicant/reapplicant during the review and approval process.
The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid

Question 4

DNV NIAHO for Hospitals
Medicare/Medicaid Sanctions

Answer 4

MS SR 11(c) Bylaws provide mechanism for immediate and automatic suspension of privileges due to the termination or revocation of Medicare of Medicaid status.
MS 6 SR 4(e) OIG Medicare/Medicaid MS8 SR1e and SR2e Exclusions must be primary source verified at initial, reappointment and when granting temporary privileges

Question 5

URAC Health Plan
Medicare/Medicaid Sanctions

Answer 5

Medicare/Medicaid sanctions are required to be reported on the credentialing application. The organization can verify with the issuing organization or NPDB. The organization may determine a timeframe for collecting sanction history, such as within the past 5 years.
Time limit: must be verified within 180 days of the credentialing decision

Question 6

AAAHC for Ambulatory Health Care
Medicare/Medicaid Sanctions

Answer 6

The application includes information concerning Medicare/Medicaid sanctions and is reviewed on initial and reappointment

Question 7

Medicare Hospital COPS and Interp Guidelines
Medicare/Medicaid Sanctions

Answer 7

Not specifically addressed