Monitoring Provider Sanctions for the Federal Employees Health Benefit Program
- Participating Physician Groups (PPG)
The United States Office of Personnel Management (OPM) has statutory and regulatory authority to exclude health care providers from participation in the Federal Employees Health Benefit Program (FEHBP). Debarment and suspension prohibit a health care provider from receiving payment for services and supplies provided to an FEHBP member on or after the effective date of their debarment and suspension actions.
Under the authority of the Federal Employees Health Benefits Amendments Act of 1988 (5 USC §8902a) and the Government-wide Nonprocurement Debarment and Suspension Common Rule (Executive Order 12549 and 5 CFR Part 970), the Administrative Sanctions Branch debars from participation in the FEHBP health care providers who have lost professional licensure, been convicted of a crime related to delivery of or payment for health care services, violated provisions of a federal program, or are debarred by another federal agency.
Monitoring for Suspended and Debarred Providers
The names of health care providers who have been debarred or suspended by the OPM are published in the Excluded Parties List System (EPLS) available online at www.sam.gov. Select the Extracts tab and access the Exclusions Extract Data Package heading. As a contracting health plan for FEHBP, Health Net is required to monitor these providers to validate Health Net is not credentialing or paying debarred or suspended providers for services rendered to members enrolled in Health Net's FEHBP. Health Net requires its delegated participating physician groups (PPGs) to monitor this site as well, when credentialing physicians and paying claims.
PPGs must check this website through their credentialing departments when bringing these physicians on board, and also on a monthly basis going forward to ensure claims for these suspended or debarred providers are not paid.
Health Net and PPG claims departments also must check this list for non-participating providers who are suspended or debarred to ensure that they are not paid for services rendered to Health Net members while sanctioned.
Claims Payment for Suspended and Debarred Providers
Health Net must notify FEHBP members who obtain services from a debarred or suspended provider. OPM regulations prescribe a 15-day grace period after issuance of the notice, during which time services rendered by the health care provider are still covered. No payments are made for services rendered more than 15 days after the date of notice to the member