Monthly Notification of Sanction Actions

4.10.4.1 - Monthly Notification of Sanction Actions (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The Medicare Exclusion Database (MED) is a standard format, cumulative exclusion database that contains information on all exclusions and reinstatement actions in Medicare, Medicaid, and other Federal health care programs. CMS receives this information from the OIG monthly. The UPICs, SMRCs and MACs shall use the information contained in the MED and the Government Accountability Office (GAO) Debarment list to: • Determine whether a physician/practitioner/provider or other health care supplier who seeks approval as a provider of services in the Medicare/Medicaid programs is eligible to receive payment; and • Ensure that sanctioned providers are not being inappropriately paid. The dates reflected on the MED are the effective dates of the exclusion. Exclusion actions are effective 20 days from the date of the notice. Reinstatements or withdrawals are effective as of the date indicated. The MED shows the names of a number of individuals and entities where the sanction period has expired. These names appear on the MED because the individual or entity has not been granted reinstatement. Therefore, the sanction remains in effect until such time as reinstatement is granted. The UPICs, SMRCs and MACs shall check their systems to determine whether any physician, practitioner, provider, or other health care worker or supplier is being paid for items or services provided subsequent to the date they were excluded from participation in the Medicare program. In the event a situation is identified in which inappropriate payment is being made, the contractors shall notify OIG and take appropriate action to correct the situation. In addition, UPICs shall consider the instructions contained in the CMP section of the PIM (PIM, chapter 4, §4.11). The UPICs and SMRCs shall work with the MACs to document a process in the JOA to make the MAC aware of any payments to an excluded provider. The MACs shall ensure that no payments are made after the effective date of a sanction, except as provided for in regulations at 42 CFR 1001.1901(c) and 489.55. The MACs shall check payment systems periodically to determine whether any individual or entity who has been excluded since January 1982 is submitting claims for which payment is prohibited. If any such claims are submitted by any individual in any capacity or any entity who has been sanctioned under §§1128, 1862(d), 1156, 1160(b) or 1866(b) of the Act, UPICs shall forward them to OIG/OI. In addition, MACs shall refer to the RO all cases that involve habitual assignment violators. In cases where there is an occasional violation of assignment by a provider, they shall notify the provider in writing that continued violation could result in a penalty under the CMP Law.