The California Medicaid program, known as Medi-Cal, is a highly regulated program by any measure. California takes a very intensive approach to assure that organizations offering services to Medicaid recipients meet a very high level of service and quality. The exclusion screening requirements established by the state reflects this approach to program integrity as well.
The state requires Medi-Cal contractors to screen the federal exclusion lists not less than monthly. These include the HHS-OIG’s List of Excluded Individuals and Entities (LEIE) and the GSA’s SAM.gov database as well as those others listed below. Contractors are also required to routinely check the state’s Medi-Cal exclusion list, known as the Suspended and Ineligible List.
Recently, California added two more Medi-Cal specific lists to these monthly screening requirements:
- Restricted Provider Database (RPD)
- Procedure/Drug Code Limitation List
This article is to provide a high-level review of the California Medi-Cal exclusion screening requirements, including the recently added California-specific lists.
California’s Medi-Cal Program and Exclusion Standards
Medi-Cal law, Welfare and Institutions Code (W&I Code), sections 14043.6 and 14123, mandate that the Department of Health Care Services (DHCS), which is the state regulator responsible for the Medi-Cal program, suspend a contracted provider of health care services from participation in the Medi-Cal program when the individual or entity has:
- Been convicted of a felony;
- Been convicted of a misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service;
- Been suspended from the federal Medicare or Medicaid programs for any reason;
- Lost or surrendered a license, certificate, or approval to provide health care; or
- Breached a contractual agreement with the Department that explicitly specifies inclusion on this list as a consequence of the breach.
The Affordable Care Act of 2010, section 6501, further strengthened Medicaid program integrity by requiring state Medicaid agencies to terminate the participation of any individual or entity if such individual or entity is terminated under Medicare or any other State Medicaid plan. This change effectively prevents bad actors from continued participation in federal health care programs by moving from state to state.
California Exclusion Screening Databases
Managed Care Plans (MCPs) must conduct federal and state database checks during the provider enrollment process and upon a provider’s reenrollment to ensure that the provider continues to meet enrollment criteria. MCPs must conduct monthly checks of the Open Data Portal, which is updated monthly, and all exclusionary data sources.
In March of 2021, DHCS issued All Plan Letter (APL) 21-003 to MCPs which clarified plan obligations when terminating or initiating terminations of contractual relationships between MCPs and their providers and subcontractors. This APL also set forth the obligation of MCPs to check exclusionary databases at least monthly and to terminate contracts with contracted providers and subcontractors suspended or excluded from participation in the Medi-Cal/Medicare programs. It was in this All Plan Letter that DHCS formalized the requirement to screen against the new lists, Restricted Provider Database (RPD) and Procedure/Drug Code Limitation List.
- Suspended and Ineligible List. This list includes Medi-Cal providers that are suspended from participation in the Medi-Cal program. It is publicly available and updated monthly by DHCS.
- List of Excluded Individuals/Entities (LEIE). This federal list is compiled, maintained and published monthly by the Office of the Inspector General of DHHS.
- SAM.gov database. The federal General Services Administration (GSA) compiles and publishes a compendium of contracting exclusions issued by multiple federal agencies. Unlike the OIG’s LEIE, the GSA issues but does not control the content of this list, but manages its compilation and issuance only.
- Social Security Administration’s Death Master File.
- National Plan and Provider Enumeration System (NPPES).
- Centers for Medicare & Medicaid Services (CMS) Medicare Exclusion Database.
- Restricted Provider Database (RPD). This California-specific list identifies providers who are placed under:
- a payment suspension while under investigation based upon a credible allegation of fraud, or
- a temporary suspension while under investigation for fraud or abuse, or enrollment violations.
This list is not in the public domain. Access to the RPD is provided to each MCP’s primary and secondary plan contact list, which is updated and maintained by DHCS Contract Managers. MCPs may continue the contractual relationship with a provider placed on this list until the state’s investigation is complete; however, reimbursements for Medi-Cal covered services will be withheld.
- Procedure/Drug Code Limitation List.This California-specific list includes providers that have been placed under a procedure or drug code limitation sanction. MCPs may continue to contract with providers placed on a procedure/drug code limitation. However, MCPs will not be paid for services provided by a restricted provider or receive reimbursement for those services under restriction. Providers who fill orders for lab tests, drugs, medical supplies, or any other restricted services prescribed or ordered by a provider under restriction will not be reimbursed.
DHCS has created two additional databases, as noted above, to ensure that Medicaid providers who are under active investigation due to a temporary suspension due to possible billing issues or fraud concerns or because of practice limitations cannot be reimbursed for services rendered to Medi-Cal enrollees.
As noted above, if a provider appears on these new California-specific lists, contract termination may not be mandatory unlike the termination requirements related to the federal lists like the LEIE or SAM.gov.
These new lists provide an additional level of review for MCPs to assure that reimbursement of their network providers meets both contract and quality expectations under their DHCS contracts. California’s screening expectations include lists that other states do not provide and require increased administrative work for MCPs. However, the additional screening also offers a heightened level of protection for Medi-Cal recipients, to assure that plan providers are not under any shadow due to their billing, referring or prescribing practices.