It is the policy of Johns Hopkins Health Plans to ensure compliance with federal and state mandates regarding reconciliation and payment of excluded providers, contractors, subcontractors, vendors, and Johns Hopkins Health Plans workforce members. 

Johns Hopkins Health Plans will do so through ongoing monitoring of:

1. All participating and non-participating providers submitting claims for reimbursement against Federal (System Award Management and Office of Inspector General List of Excluded Individuals and Entities {LEIE)) and Maryland State exclusion/sanction lists.
2. All network providers at time of initial and re-credentialing cycles.
3. All contractors, subcontractors and vendors prior to contract execution.
4. All Johns Hopkins Health Plans workforce members at time of hire and monthly thereafter.

 It is Johns Hopkins Health Plans expectation that all providers, contractors, subcontractors, and vendors perform Federal and State exclusion checks on its employees.

 Federal Health Care Program: For purposes of SSA §1128B(f), the term “Federal health care program” is defined as:

1. any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5, United States Code; or
2. any State health care program, as defined in section 1128(h).

Federal Mandatory Exclusion.—The Secretary (DHHS) shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1128B(f)) of the Social Security Act.

1. Conviction of program-related crimes.—Any individual or entity that has been convicted of a criminal offense related to the delivery of an item or service under title XVIII or under any State health care program.
2. Conviction relating to patient abuse.—Any individual or entity that has been convicted, under Federal or State law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care item or service.
3. Felony conviction relating to health care fraud.—Any individual or entity that has been convicted for an offense which occurred after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996, under Federal or State law, in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program (other than those specifically described in paragraph (1)) operated by or financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.
4. Felony conviction relating to controlled substance.—Any individual or entity that has been convicted for an offense which occurred after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996, under Federal or State law, of a criminal offense consisting of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

Permissive Exclusion.—The Secretary may exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1128B(f)).  Listed below is a partial list of where permissive exclusionary authority may be exercised.

1. Conviction relating to fraud

2. Conviction relating to obstruction of an investigation or audit

3. Misdemeanor conviction relating to controlled substance.  Any individual or entity that has been convicted, under Federal or State law, of a criminal offense consisting of a misdemeanor relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

4. License revocation or suspension.  Any individual or entity:

1. whose license to provide health care has been revoked or suspended by any State licensing authority, or who otherwise lost such a license or the right to apply for or renew such a license, for reasons bearing on the individual’s or entity’s professional competence, professional performance, or financial integrity, or
2. who surrendered such a license while a formal disciplinary proceeding was pending before such an authority and the proceeding concerned the individual’s or entity’s professional competence, professional performance, or financial integrity.

5. Exclusion or suspension under federal or state health care program.—Any individual or entity which has been suspended or excluded from participation, or otherwise sanctioned, under—

1. any Federal program, including programs of the Department of Defense or the Department of Veterans Affairs, involving the provision of health care, or
2. a State health care program,

for reasons bearing on the individual’s or entity’s professional competence, professional performance, or financial integrity.

6. Claims for excessive charges or unnecessary services and failure of certain organizations to furnish medically necessary services.—Any individual or entity that the Secretary determines

1. has submitted or caused to be submitted bills or requests for payment (where such bills or requests are based on charges or cost) under title XVIII or a State health care program containing charges (or, in applicable cases, requests for payment of costs) for items or services furnished substantially in excess of such individual’s or entity’s usual charges (or, in applicable cases, substantially in excess of such individual’s or entity’s costs) for such items or services, unless the Secretary finds there is good cause for such bills or requests containing such charges or costs;
2. has furnished or caused to be furnished items or services to patients (whether or not eligible for benefits under title XVIII or under a State health care program) substantially in excess of the needs of such patients or of a quality which fails to meet professionally recognized standards of health care;
3. is
      i. a health maintenance organization (as defined in section 1903(m)) providing items and services under a State plan approved under title XIX, or
      ii. an entity furnishing services under a waiver approved under section 1915(b)(1), 
   and has failed substantially to provide medically necessary items and services that are required (under law or the contract with the State under title XIX) to be provided to   individuals covered under that plan or waiver, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals; or
4. is an entity providing items and services as an eligible organization under a risk–sharing contract under section 1876 and has failed substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under the risk–sharing contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals.

7. Makes false statements or misrepresentation of material facts.—Any individual or entity that knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact in any application, agreement, bid, or contract to participate or enroll as a provider of services or supplier under a Federal health care program (as defined in section 1128B(f)), including Medicare Advantage organizations under part C of title XVIII, prescription drug plan sponsors under part D of title XVIII, Medicaid managed care organizations under title XIX, and entities that apply to participate as providers of services or suppliers in such managed care organizations and such plans.

8. Fraud, kickbacks, and other prohibited activities.—Any individual or entity that the Secretary determines has committed an act which is described in section 1128A, 1128B, or 1129.

State Health Care Program: For purposes of this section and sections 1128A and 1128B of the Social Security Act, the term “State health care program” is defined as:

1. a State plan approved under title XIX,
2. any program receiving funds under title V or from an allotment to a State under such title,
3. any program receiving funds under subtitle I of title XX or from an allotment to a State under such subtitle, or
4. a State child health plan approved under title XXI.

Effective Date of and Termination of Exclusion, also known as reinstatement, for purposes of this policy are defined as:

1. An exclusion under this section or under section 1128A shall be effective at such time and upon such reasonable notice to the public and to the individual or entity excluded as may be specified in regulations.
2. Exclusion shall be effective with respect to services furnished to an individual on or after the effective date of the exclusion.
   1. An Exception to this rule is:

               i.      Unless the Secretary determines that the health and safety of individuals receiving services warrants the exclusion taking effect earlier, an exclusion shall not apply to payments made under title XVIII or under a State health care program for:

                 1.      inpatient institutional services furnished to an individual who was admitted to such institution before the date of the exclusion, or

                 2.      home health services and hospice care furnished to an individual under a plan of care established before the date of the exclusion,

               ii.      In these two instances until the passage of 30 days after the effective date of the exclusion.

       3.  An individual or entity excluded (or directed to be excluded) from participation under §1128A may apply to the Secretary, at the end of the minimum period of exclusion provided for termination of the exclusion.

                     a. The Secretary may terminate the exclusion if the Secretary determines, on the basis of the conduct of the applicant which occurred after the date of the notice of exclusion or which was unknown to the Secretary at the time of the exclusion, that

                i.      there is no basis for a continuation of the exclusion, and

                ii.      there are reasonable assurances that the types of actions which formed the basis for the original exclusion have not recurred and will not recur.

                      b.  The Secretary is required to promptly notify each appropriate State agency administering or supervising the administration of each State health care program of the fact and circumstances of each termination of exclusion made under this subsection.

4. Exception for provision of emergency services. 42 C.F.R. §1001.1901(c)(5).

1. That exception states: "(5)(i) Notwithstanding the other provisions of this section, payment may be made under Medicare, Medicaid or other Federal health care programs for certain emergency items or services furnished by an excluded individual or entity, or at the medical direction or on the prescription of an excluded physician or other authorized individual during the period of exclusion. To be payable, a claim for such emergency items or services must be accompanied by a sworn statement of the person furnishing the items or services specifying the nature of the emergency and why the items or services could not have been furnished by an individual or entity eligible to furnish or order such items or services.
2. Notwithstanding paragraph I(5)(i) of this section, no claim for emergency items or services will be payable if such items or services were provided by an excluded individual who, through an employment, contractual or any other arrangement, routinely provides emergency health care items or services.”
3. The Maryland MCO Conditions of Participation regulations (10.67.04.02), Section L(2), states that an MCO “may not employ or contract with providers excluded from participation in federal health care programs under either §1128 or 1128A of the Social Security Act" but may, in circumstances as outlined above, pay amounts to excluded providers for “emergency services” as defined in COMAR (10.09.36.01).  

Regulatory citations

SSA §1128
CHAMPUS 32 C.F.R. §199.2 and 199.9(f)(1)
42 C.F.R. §1001.1901(c)(5)
COMAR 10.09.36.08(11-1)
COMAR 10.67.04.02
COMAR 10.67.03.03
Md. Stat. Health Section 19-701