Federal law prohibits Medicare, Medicaid and other federal healthcare programs from paying items or services provided by a person or entity excluded from participation in these federal programs. This means that CareFirst Medicare Advantage and its FDRs must utilize the Office of the Inspector General’s List of Excluded Individuals/Entities (LEIE) and the General Services Administration (GSA) websites to ensure that all employees and contractors who either provide or assist with administrative and/or health care or prescription drug services for CareFirst Medicare Advantage Medicare plans.
OIG’s LEIE provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare and other Federal health care programs. The effect of an exclusion is that no payment will be made by any Federal health care program for any items or services furnished, ordered or prescribed by an excluded individual or entity. No program payment will be made for anything that an excluded person furnishes, orders, or prescribes. This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, any hospital or other provider for which the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person. CMS prohibits payments by CareFirst Medicare Advantage directly or indirectly to anyone on this list or on the GSA/SAM list.
FDRs must review a number of federal excluded persons, sanction and debarment lists such as the U.S. Department of Health and Human Services (HHS) – Office of Inspector General (OIG) and General Services Administration (GSA), at the time of hire/contracting and monthly thereafter for their current employees/contractors, health care professionals, or vendors that work on Medicare Advantage or Part D programs to ensure that none are excluded from participating in Federal health care programs. For more information or access to the publicly accessible online databases, please see the following links: