Exclusions list protects Texas Medicaid

Exclusions list protects Texas Medicaid

One way the OIG protects the health and well-being of Medicaid clients is by excluding certain people or businesses from participating as Medicaid providers. Those excluded are added to the Texas Exclusions List. Medicaid providers are responsible for ensuring they do not employ anyone listed on the state or federal OIG exclusion lists. The requirements apply to not only health care practitioners, such as doctors and nurses, but also to other employees, such as front office staff.

What leads to exclusion?

In FY 2023, Texas excluded 208 providers of all types from HHS program participation. 155 have been excluded in the first three quarters of FY 2024.

Federal and state OIGs may prohibit people or businesses from participating as Medicaid providers for several reasons. Typical actions that have led to exclusion include:

• Loss of license or other certification to practice.
• Prior criminal convictions for certain offenses, such as health care fraud.
• Patient harm or delivering services below the profession’s standard of care.
• Billing for services not rendered or not medically necessary.
• Illegal solicitation of clients or offering kickbacks in exchange for business.

The consequences of exclusion

When a person or entity is excluded from Medicaid or other HHS programs, they may not be reimbursed or request to receive reimbursement for providing goods or services performed under Medicaid or any other HHS program. Excluded providers also may not assess care or prescribe services to HHS program recipients. Exclusions, whether by the federal OIG or any state OIG, are effective nationwide. Providers are prohibited from employing excluded staff in any capacity, such as dental assistants and clerical staff. In addition, a provider employing an excluded person may not bill Medicaid or any other HHS program for the excluded employee’s services. Submitting claims for payment for an excluded employee’s services could result in recoupment of any compensation paid to the ineligible worker, provider termination, provider exclusion and monetary penalties.

OIG case examples

A dentist was excluded from participating in Medicaid and other HHS programs for 10 years for illegally soliciting Medicaid clients by paying a per-person fee to a marketer for each patient brought to the dentist’s practices for care.

A Consumer Directed Services (CDS) employer in Lubbock County was excluded from Texas Medicaid for 20 years. An OIG investigation determined the individual submitted claims for services that were not rendered, failed to manage personal care attendants’ services and failed to carry out the responsibilities of a CDS employer from 2015 through 2021. The individual also failed to produce records to the OIG upon request.

Providers can be excluded as the result of an OIG investigation, but often cases arise because a provider or their practice employed an excluded individual.

The OIG settled a case where a ground ambulance corporation reported that an emergency medical technician they employed was excluded under her maiden name, and the exclusion was missed when searching the employee’s current married name. Once the exclusion was discovered, the provider disclosed the error to the OIG and repaid $30,939.

An El Paso provider self-disclosed that they employed an excluded person from August 2022, through February 2023. The provider correctly reported that it owed the Medicaid program $38,819, and the OIG agreed to resolve the claims through settlement.

The Texas Exclusions List is a powerful tool in the OIG’s arsenal to prevent bad actors from exploiting Texas tax dollars. However, health care employers themselves play a critical role in the process by ensuring their employees are not barred from participation.