Program Integrity - Exclusion Program

Program Integrity (PI) administers the Department of Health and Human Services' (DHHS) MaineCare Exclusion Program. Excluded individuals or entities are prohibited from enrolling as MaineCare providers or servicing providers. In addition, MaineCare providers are prohibited from employing, directly or indirectly, excluded individuals or entities. Federal regulations prohibit payment for any item or service furnished, ordered, or prescribed by an excluded individual.

Federal citations:

42 CFR Part 1001

42 CFR Part 1002

Maine Department of Health and Human Services:

MaineCare Benefits Manual

Chapter I, § 1.03-3W

Chapter I, § 1.19

Consequences to Providers Employing or Contracting with Excluded Individuals/Entities

Please be advised that Federal law prohibits MaineCare from paying providers that employ or contract with excluded individuals or entities. If the Maine DHHS receives information that a provider is employing an excluded person, it will inform the provider that they must either immediately terminate the excluded individual or provide clear evidence that the individual is not being reimbursed directly or indirectly from state and/or federal funds and is not providing services to MaineCare or Medicare members. Failure to do so may result in termination of the provider's participation in the MaineCare Program and because Federal law prohibits DHHS from receiving any Federal funding for payments made to providers employing excluded individuals, all MaineCare payments would cease immediately.

DHHS also informs the Healthcare Crimes Unit of the Maine Attorney General's Office and the U.S. Department of Health and Human Services' Office of Inspector General (OIG) of the exclusion violation.

In addition to any prison term and/or restitution ordered against the excluded individual, the affected health care providers may be required to reimburse MaineCare and/or Medicare all payments associated with the excluded individual or the salaries/wages, including fringe benefits paid to these individuals.  Civil monetary penalties of as much as $15,000 per claim may be imposed against a provider who employs or contracts with an excluded individual or entity.

Providers Should Screen for Excluded Individuals of Entities

Providers are required under the MaineCare Provider/Supplier Agreement and the MaineCare Benefits Manual Chapter I, § 1.03-3 W to ensure that "excluded individuals or entities are not employed or utilized to provide services, receive payments, or submit claims, to the MaineCare Program." The Department strongly recommends that providers screen all their employees and contractors for exclusions. We would also recommend that providers require their contractors to screen their staff for excluded individuals. Providers should screen all new potential employees prior to hire and routinely screen all staff at set time intervals, i.e. annually, quarterly, etc.

OIG Searchable Database on the Web

The OIG website has a searchable database that is accessible to providers and the general public. The database provides information on excluded individuals and entities. The website is located at http://oig.hhs.gov/fraud/exclusions.asp and is in two formats. The on-line version allows providers to search by name (it is recommended that providers attempt to obtain all aliases and/or former names when possible). If a match is identified  the database allows the user to verify the information by entering a Social Security Number (SSN) or Employer Identification Number (EIN). Providers may elect to use the downloadable version and compare it to their employee database. The downloadable version does not include the SSN or EIN. If a match is discovered the provider should return to the on-line version to verify the SSN or the EIN.

Reporting Exclusion Violations

strongProgram Integrity strongly urges healthcare providers to continually screen their staff and contractors through the exclusion databases and immediately report any exclusion violations to Program Integrity at (207) 287-4660.

Effect of Exclusions

The listing below is from the 1999 HHS-OIG Special Advisory Bulletin: The Effect of Exclusion From Participation in Federal Health Care Programs. This list provides examples of the types of items or services that are not reimbursable by MaineCare and/or Medicare if furnished, ordered, or prescribed by an excluded individual:

  • Services performed by excluded nurses, technicians, or other excluded individuals who work for a hospital, nursing home, home health agency or physician practice, where such services are related to administrative duties, preparation of surgical trays or review of treatment plans if such services are reimbursed directly or indirectly (such as through a pay per service or a bundled payment) by a Medicaid program, even if the individuals do not furnish direct care to Medicaid recipients
  • Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling prescriptions for drugs reimbursed, directly or indirectly, by a Medicaid program
  • Services performed by excluded ambulance drivers, dispatchers and other employees involved in providing transportation reimbursed by a Medicaid program, to hospital patients or nursing home residents
  • Services performed for program recipients by excluded individuals who sell, deliver or refill orders for medical devices or equipment being reimbursed by a Medicaid program
  • Services performed by excluded social workers who are employed by health care entities to provide services to Medicaid recipients, and whose services are reimbursed, directly or indirectly, by a Medicaid program
  • Services performed by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer that are related to and reimbursed, directly or indirectly, by a Medicaid program
  • Items or services provided to a Medicaid recipient by an excluded individual who works for an entity that has a contractual agreement with, and is paid by a Medicaid program and
  • Items or equipment sold by an excluded manufacturer or supplier, used in the care or treatment of recipients and reimbursed, directly or indirectly, by a Medicaid program