This Web site contains a list of individuals or entities whose participation in the Medicaid program has been restricted, terminated or excluded under the provisions of 18 NYCRR § 504.7(b) - (h), 18 NYCRR §515.3, or 18 NYCRR §515.7. Not every action taken by the OMIG/DOH involves a finding of wrongdoing, and there should be no negative connotations associated with terminations of providers “without cause” (see NYCRR §504.7). While the Restricted/Terminated/Excluded List contains those entities and individuals that have been terminated “for cause,” the list does not contain the names of individuals/entities that have been terminated “without cause,” as those individuals are generally still entitled to order or prescribe care, services or supplies.

However, upon a determination that a provider has failed to meet prescribed statutory or regulatory obligations, including committing one (or more) unacceptable practices, the OMIG/DOH, in some circumstances, has the discretion to, and in others must, impose a sanction against the provider (see NYCRR §515.2, §515.3 and §515.7). In some cases, the OMIG/DOH can also impose a sanction against any affiliates of the provider (see NYCRR §515.8), or where a sanction is mandatory and must be imposed against a provider (see NYCRR §515.3). Sanctions can include: exclusion from the program for a reasonable period of time, censure, or conditional or limited participation, such as requiring pre-payment review or prior authorization of claims for all medical care, services or supplies, and recoupment of overpayments (see NYCRR §515.3, §515.4, §515.5 and §515.7).

It is considered an unacceptable practice to submit claims or accept payment for medical care, services or supplies furnished by a person suspended, disqualified, or otherwise terminated [with cause] from participation in the program or furnished in violation of any condition of the program [see §515.2 [b][7]]. Further, a person who is excluded from the program cannot be involved in any activity relating to furnishing medical care, services or supplies to recipients of medical assistance for which claims are submitted to the program, or relating to claiming or receiving payment for medical care, services or supplies during the period [see §515.5(c)].

Other healthcare providers may also be included on this list if they have failed to meet certain prescribed participation requirements and are therefore precluded from ordering or prescribing care, services or supplies, exclusive of in-patient hospital care [See NYCRR §504.1(d)(19)].

Use of this list will help providers to avoid denial of claims and will help the OMIG/DOH ensure that claims for medical care, services and/or supplies are ordered or prescribed by individuals permitted to order or prescribe under the Medicaid program. All orders or prescriptions that enrolled providers receive should be checked to verify that the orderer has not been excluded or restricted. If the orderer or prescriber’s name appears on this list, Medicaid should not be billed for the care, services or supplies ordered, prescribed or provided by that person or entity. Any claims submitted for medical care, services or supplies ordered/ prescribed by any providers appearing on this list may be denied, and the enrolled provider dispensing prescriptions or filling orders may be held responsible for repayment of any payments made by the Medicaid program under these circumstances.

For orders or prescriptions requiring prior approval or prior authorization, it should be noted that the receipt of an approval or authorization is not a guarantee of payment.  Payment is subject to a patient’s eligibility and compliance with all applicable statutes and policy, including those stated in this letter.

Providers are reminded that they should check this list on a monthly basis at a minimum. This will enable you to capture exclusions and terminations that may have taken place since the last search. The OMIG’s site allows you to select the “short list” option, which offers a list of all changes that have taken place over the previous 30 days.

Disclaimer:

The Office of the Medicaid Inspector General has attempted to ensure that all of the information contained in this listing is as accurate as possible. However, the OMIG makes no warranty or guarantee either expressed or implied concerning the accuracy of the content of the Web site. No posted information or materials provided are intended to constitute legal or medical advice.

Should you have a question regarding this notice or the status of any of the providers contained on this list, please contact Peter Zayicek, Office of the Medicaid Inspector General, at (518) 474-9739. If you would like additional information about the termination or exclusion of any Medicaid provider, please make a Freedom of Information Law (“FOIL”) request. Information about making a FOIL request can be found at http://www.health.state.ny.us/nysdoh/phforum/foil/foil.htm.

Reinstatement into the Medicaid Program and/or Removal from the Medicaid Restricted/Terminated/Excluded List

Reinstatement into the Medicaid program and/or removal from the Restricted/Terminated/Excluded list may be granted if the OMIG is reasonably certain that the violations that led to the restriction/termination/exclusion will not be repeated. [See §515.10(e)].

To be reinstated into the Medicaid program, an enrollment/reinstatement application must be submitted. The OMIG has 90 days to complete its review and render a decision. Decisions for reinstatements are based on information submitted with the application. It is the responsibility of the applicant to provide information and/or documentation detailing corrective steps taken to assure the OMIG that the violations that led to the exclusion will not be repeated. If the applicant is denied reinstatement based upon prior conduct, the applicant cannot re-apply for reinstatement for two years from the date of the denial [See §504.5(d)].

Applications for provider reinstatement may be obtained by accessing www.eMedny.org, and clicking on information and then clicking on Provider Enrollment Forms (same form/process as initial enrollment). Individuals who do not enroll in the Medicaid Program who seek removal from the Restricted/Terminated/Excluded list should contact John Sitterly in the OMIG’s Bureau of Investigations and Enforcement at (518) 408-0853.