In the complex world of healthcare regulations, staying informed about the Centers for Medicare & Medicaid Services (CMS) guidelines is crucial—especially when it comes to compliance and provider eligibility. One important tool CMS uses to protect the integrity of federal healthcare programs is the Preclusion List. But what exactly is the CMS Preclusion List, and why does it matter?
What Is the CMS Preclusion List?
The CMS Preclusion List is a list of healthcare providers, prescribers, and entities that are precluded from receiving payment for items or services provided to Medicare beneficiaries. This list is separate from the Office of Inspector General (OIG) Exclusion List, though there can be some overlap.
Providers and prescribers on the CMS Preclusion List cannot be reimbursed by Medicare Advantage (Part C) or Medicare Part D for their services or prescriptions. This restriction applies even if the provider holds a valid license and is not listed on other exclusion databases.
Why Are Providers Placed on the Preclusion List?
Providers can be added to the Preclusion List for a number of reasons. One of the most common is having their Medicare billing privileges revoked. This could happen due to non-compliance, fraud, or other administrative issues. CMS might also place someone on the list if they have been convicted of a felony that is considered harmful to the Medicare program, such as healthcare fraud or unlawful prescribing practices.
Additionally, if another federal agency suspends or excludes a provider, CMS may also take action to include that individual or entity on the Preclusion List.
How Does It Affect Medicare Plans and Patients?
If a provider is on the CMS Preclusion List, Medicare Advantage and Medicare Part D plans are required to deny payments for any services or prescriptions associated with that provider. This means pharmacies won’t fill prescriptions from precluded providers under Medicare Part D, and Medicare Advantage patients may be unable to see certain doctors or specialists.
Patients will usually receive a notification if their provider is added to the list, giving them the opportunity to choose a new provider.
What’s the Difference Between the CMS Preclusion List and the OIG Exclusion List?
Although both lists serve to protect federal healthcare programs, they are not the same. The OIG Exclusion List blocks individuals from participating in all federal healthcare programs, including Medicare and Medicaid. The CMS Preclusion List specifically prevents payment under Medicare Advantage and Medicare Part D. Importantly, the CMS list is not publicly available. Only Medicare plans and authorized entities can access it.
How Can a Provider Get Off the List?
Getting removed from the CMS Preclusion List depends on the reason for being added in the first place. If a provider was added due to revoked billing privileges, they may be able to re-enroll once the revocation period ends—typically after one to three years. Providers also have the right to appeal CMS’s decision and request a reconsideration.
The appeals process usually involves submitting additional documentation and making a case for reinstatement. If CMS agrees that the provider no longer poses a risk to the program, they may remove the name from the list.
Why Compliance Matters
For healthcare providers, being on the CMS Preclusion List can have serious consequences. Not only does it impact income and patient relationships, but it also damages professional reputation. That’s why ongoing compliance is so important. Providers should stay updated on CMS guidelines, keep accurate records, and ensure they respond quickly to any communication from CMS.
Using compliance tracking tools or working with legal and administrative consultants can help providers avoid unintentional violations that might lead to preclusion.
Conclusion
The CMS Preclusion List is more than just another regulation—it’s a powerful tool that ensures only eligible, ethical providers are part of the Medicare Advantage and Part D networks. For professionals in the healthcare field, understanding how this list works—and how to stay off it—is crucial. By staying informed and compliant, providers can continue delivering quality care while avoiding the risks associated with federal sanctions.
