CMS Pub. 100-16, ch. 6, § 60.2

Excluded and Opt-Out Provider Checks

(Rev. 24, 06-06-03)

Excluded Providers

The Office of the Inspector General (OIG) maintains a sanction list that identifies those

individuals found guilty of fraudulent billing, misrepresentation of credentials, etc. The

MA organizations employing or contracting with health providers have a responsibility to

check the sanction list with each new issuance of the list, as they are prohibited from

hiring, continuing to employ, or contracting with individuals named on that list. The MA

organizations should check the Office of the Inspector General (OIG) Web site at

http://www.oig.hhs.gov/fraud/exclusions/list of excluded.html for the listing of excluded

providers and entities. The OIG has a limited exception that permits payment for

emergency services provided by excluded providers under certain circumstances. See

42 CFR 1001.1901.

Opt-Out Providers

If a physician or other practitioner opts out of Medicare, that physician or other

practitioner may not accept Federal reimbursement for a period of 2 years. The only

exception to that rule is for emergency and urgently needed services where a private

contract had not been entered into with a beneficiary who receives such services. See

42 CFR 405.440. An MA organization must pay for emergency or urgently needed

services furnished by a physician or practitioner to an enrollee in their MA plan who has

not signed a private contract with a beneficiary, but may not otherwise pay opt-out

providers. Information on providers who opt-out of Medicare may be obtained from the

local Medicare Part B carrier. The MA organization must check this list on a regular

basis.

(Source: 42 CFR 422.204(b)(4) and 42 CFR 422.220 and additional instructions.)