4/22/2024

Provider Screenings: Stay Compliant and Protect Your Practice

The Office of Inspector General (OIG) has a legal responsibility to exclude individuals and entities convicted of certain criminal offenses from participating in federal health care programs. Pennsylvania also has its own requirements for licensing, education, and eligibility for providing medical services. And the Affordable Care Act (ACA) requires background checks for high-risk specialties.

As a reminder, if you participate in Medicare or Medicaid, you should regularly monitor the following:

  • List of Excluded Individuals/Entities (LEIE)
  • Excluded Parties List System (EPLS)
  • Social Security Administration’s Death Master File
  • National Plan and Provider Enumeration System
  • Pennsylvania Medicheck
  • Criminal background checks

By actively monitoring providers’ eligibility, your practice can stay compliant and avoid operational disruptions, revenue loss due to refunds, and negative impacts on patient care.  Any payments made for services provided or billed by an excluded or sanctioned provider will be recouped by Highmark Wholecare. 

If you have any questions, don’t hesitate to call the Fraud, Waste, and Abuse (FWA) hotline at 844-718-6400.

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