Under the exclusion statute, whose billing is prohibited for the services of an excluded provider?

Under the exclusion statute, whose billing is prohibited for the services of an excluded provider?

• A. The excluded provider
• B. The employer of the excluded provider
• C. The patient
• D. The state Medicaid agency

Answer: (B)

The key idea is that the exclusion sticks not only to the individual but to anyone who would bill for that person’s services. The statute targets the entity that would submit the claim to federal health care programs for the work of the excluded provider. Therefore, the employer or organization that hires or contracts with the excluded provider is prohibited from billing federal programs for the services the excluded individual renders. This prevents a workaround where a program would appear to pay a different clinician while effectively reimbursing the same excluded practitioner’s work. In practice, if a clinic employs an excluded provider, that clinic cannot bill Medicare or Medicaid for the services performed by that provider. The patient may still receive care, but the billing to the federal program cannot be made on the excluded provider’s behalf.

The key idea is that the exclusion sticks not only to the individual but to anyone who would bill for that person’s services. The statute targets the entity that would submit the claim to federal health care programs for the work of the excluded provider. Therefore, the employer or organization that hires or contracts with the excluded provider is prohibited from billing federal programs for the services the excluded individual renders. This prevents a workaround where a program would appear to pay a different clinician while effectively reimbursing the same excluded practitioner’s work. In practice, if a clinic employs an excluded provider, that clinic cannot bill Medicare or Medicaid for the services performed by that provider. The patient may still receive care, but the billing to the federal program cannot be made on the excluded provider’s behalf.