New Jersey’s origin stems from Revolutionary War times when settlers wanted to find and cultivate a new land and pay homage to Jersey, the largest of the British Channel Islands. Today, it is a northeastern state that, to its north abuts New York City and to the south, Pennsylvania. New Jersey is one of over 40 states that publishes a state Medicaid exclusion list.

New Jersey has had a Medicaid exclusion list for quite some time, but this week some new and interesting activity has taken place. In general, states typically update their exclusion list on a weekly, monthly, quarterly or annual basis. According to the official New Jersey Medicaid Disqualified Providers website, NJ updates their list monthly. Just this week, 174 NEW exclusions were added with effective dates ranging from 6 months to over 12 months ago. Our data team took a closer look at this predicament, and here’s what they found…

State of New Jersey Disqualified Provider Information

This week, New Jersey uploaded 174 *new* exclusions with exclusion dates up to 1 year in the past. As of February 14th, 2018 there are a total of 3,027 excluded individuals and entities. During this time, 2,674 of these exclusions are individuals and 353 are entities.

Well, let’s take a closer look at the 174 exclusions or “disqualified parties” that were presented this week.

• 111 exclusions from 12 months ago
• 61 exclusions from 6-11 months ago
• 2 exclusions from over 12 months ago

Here is an example of one of the oldest exclusions recently reported on the list:

• JESSICA FELIX, exclusion date 08-14-2015

How can exclusions occur in years past, but just now be published on the exclusion site?

There are many possible explanations. First, there may be exclusions that have been caught in an audit and are now being added. Second, the New Jersey Medicaid Fraud Control Unit may not have reported these when originally pursued by the MCFU, but are now being reported to the exclusion source. Third, could be due to lack of staffing and resources by the agency, as we have seen in other states. Other reasons could be provided by New Jersey but were not noted in the latest update. Fourth, the delays could be due to the timelines of issuance of Orders. Other reasons could be provided by New Jersey but were not noted in the latest update.

How Important Are Effective Dates for State Medicaid Exclusions?

Very important! The New Jersey state Medicaid exclusion site outlines the impact of having an excluded person or entity working for you or with your organization.

It states, “A disqualified provider is a person or an organization that has been excluded from participation in federal or state-funded health care programs including but not limited to Medicare or Medicaid. Any products or services that a disqualified provider furnishes, orders or prescribes are not eligible for payment under those programs. This payment prohibition extends to anyone who employs or contracts with the disqualified provider, as well as to any facility where the disqualified provider delivers services that might otherwise be reimbursable.”

What if I find an exclusion now, but the date was in the past?

Legally, you are on the hook only after the state publishes the exclusion on their list. The standard is what the employer “knew or should have known”. Theoretically, it is not possible to know until it is published.

So, for example, if you have been monitoring a person or entity that was not on the list prior to the February upload date by New Jersey, but is now on the list AND the date of the exclusion was in the past (prior to the February upload date) you should document the diligence you had conducted prior to that point, and then review the exclusion as of today to determine what you will do as a result of the now published exclusion.  

Best Practice for State Medicaid Exclusion Monitoring: New Jersey

Best practice would be to rescreen all employees through this New Jersey update to ensure that none of your employees, contractors or third parties were in the list of 174 “new” exclusions with dates in the past.

If this is news to you, please contact us to discuss. We want to help you streamline your New Jersey exclusion monitoring and keep you up to date on the very important issue these newly updated, but “old” exclusions, have created.

Contact us at 615-938-7878 or sales@providertrust.com.  

* Disclaimer: ProviderTrust is not a law firm, nor is it providing legal advice in this article. The opinions contained herein, are recommendations and not to be relied upon as legal advice.

Written by Michael Rosen, ESQ