Wiki Help with New PA-C

[eharloff]

My office hired in a new grad PA-C (eff. 9/2023). Her first day with us was October 30, 2023 and we've ran into a few bumps in the road.

Our biggest concern is:

She is not yet credentialed with Medicare. I am not quite sure if since she is not yet credentialed with Medicare, if she's able to see patients with a Medicare Advantage plan? I've told my manager and the MDs I work with about this, but they just seem to think it is not a big deal, but I am not going to bill something we should not be billing.

Thanks in advance for any information/guidance!

 

[jkyles]

Hi there, so long as the PA enrolled with the MA plans they're billing and not on a Medicare preclusion list you should be fine.

 

[eharloff]

Hi there, so long as the PA enrolled with the MA plans they're billing and not on a Medicare preclusion list you should be fine.

How do I find a preclusion list? Thanks!

 

[CBLENNIE]

Here is the link to the List of Excluded Individuals/Entities (LEIE) searchable database. This database is maintained by the OIG for HHS and here is a link to information on the Exclusions Program.

Please note that providers excluded from participating in traditional Medicare are also excluded from participating in any MA plans. These providers are excluded from participating in any federally funded health care programs, including Medicaid if they are excluded under Section 1128 of the act. If the provider is excluded under Section 1156, they are excluded from participating in Medicare and/or any State health care program.

 

[jkyles]

The preclusion list isn't publicly available. CMS maintains the list and Medicare Advantage plans are responsible for making sure they don't pay providers who are precluded. The list includes providers who were never enrolled in Medicare or who had their enrollment revoked.

If a provider has been precluded they will have received a letter. You can read more about preclusion here. www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/preclusion-list.

 

[csperoni]

I think we went down a rabbit hole with the preclusion list. It would be rather rare for a new PA graduate to be on the Medicare provider exclusion list. I suppose it's possible, but even in general, a very, very small percentage of providers are on that list. It's basically for people who were caught doing shady stuff.
So, let's assume your new PA is not on this list. Then going back to @jkyles original answer, as long as the provider is credentialed with the insurance of the patient being seen, there should not be an issue.