If Birds Of A Feather Flock Together, Your “Flock” Could Cost You!

There are many uncertainties about the Affordable Care Act. Despite the uncertainties, there are some parts of Obamacare that are crystal clear…especially when it comes to MONEY. Let’s look at a one of them.

Many states are expanding their Medicaid programs, which will extend eligibility to millions. Medicaid programs provide Dental care for children. This, in-turn, will stress many state’s Medicaid Dental programs as fewer and fewer Dentists are willing to subject themselves to increased government standards and certain scrutiny. This now causes a domino effect with access to care issues, which most localities are working hard to relieve. All thanks to the double-edged sword known as Obamacare.

The general sentiment among many Dentists is, why bother participating with Medicaid or CHIP? Great question! I, for one, am not going to tell you I think this is a good idea. In fact, I believe having a practice that is largely dependent on Medicaid is a terrible idea. If I had a Dental license and could own a Dental practice, there is no way in heck, even with all the compliance and accountability systems I have, I would ever take Medicare, Medicaid, CHIP or ANY other government Dental program. When you cash checks issued to you by the government, there are strings…no there are large ropes…attached to that money. Once you deposit those funds in your account you can be hung by all those ropes and the regulations forming a hangman’s noose.

Section 6401 of the Affordable Care Act outlines very specific provider screening requirements. In a nutshell, the ACA states that State Medicaid programs must step-up their credentialing process to include criminal background checks, license and qualification verification, and exclusion checks. The first two are pretty self-explanatory. The latter, exclusion checks, not-so-much.

 Dental Compliance Packages and Solutions

The government is increasing the use of a disciplinary tool known as “program exclusion” for dealing with people (not just providers) who are convicted (civilly or criminally) for patient abuse or healthcare fraud related to government-funded health programs, including by not limited to Medicare, Medicaid and CHIP. Recent indicators suggest this also includes TRICARE, which is a government program rom which many Dentists accept money. People can also be excluded from participation for failure to repay Health Education Assistance Loans that Dentists and auxiliary obtain to pay for their education. Additionally, certain criminal convictions can also trigger exclusions. There are mandatory exclusions and permissive exclusions. The duration of the exclusions can vary from a year to permanent.

While State Medicaid programs check providers at credentialing or re-credentialing, the state programs do not check the provider’s staff members who may also be excluded. The onus is on the provider to ensure no employee or contractor is excluded from participation with a Federally-funded program, whether the employee or contractor is either directly or indirectly involved in any way with a product or service provided to a recipient of the program. The ACA makes is clear no provider may employ or contract with any person who is excluded from ANY State or Federal program. The expectation is for providers to check their own and police themselves. A provider’s failure to conduct exclusion (for whatever reason) is not a compelling factor when determining the provider’s liability for issues involving excluded persons.

Providers must periodically (regularly) check themselves, their staff and those with whom they contract (Dentists, temporary staff, consultants) to ensure those persons are not excluded by the Federal government or any state. There are multiple Federal exclusion lists that must be checked. Additionally, there are 23 states that have their own state list. Some states have multiple exclusion lists. But wait, it gets better.

Not only do providers have to conduct the checks, but they must record the checks (date, time, spelling of names checked) and the checks should include common names, aliases and maiden names of employees and contractors of the Dentist (provider). When the chips fall and a provider has to answer for failure to conduct exclusion checks and issues related to the acceptance of government money where excluded persons are involved, the burden is on the provider to demonstrate they did their due diligence. If they cannot prove their efforts the government wins (right, wrong or otherwise). I believe it is important to note I do not agree with this. However, I am sharing my experience with you.

Next time, we’ll take a closer look at the fines and penalties associated with failure to perform this “simple” administrative task. And let me tell, it ain’t cheap! The old saying, “You’re known by the company you keep” has now become you’re PAID and FINED – or not – by who you keep in your company!


Our clients don’t have to worry about exclusion checks! We do it for them in our GOLD program designed for Medicaid Providers. Click Here for more information.