Monitoring Provider Sanctions for the Federal Employees Health Benefit Program
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The U.S. 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 Non-procurement 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.
For non-FEHBP members, refer to Monitoring Provider Exclusions.
Monitoring for Suspended and Debarred Providers
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. For non-FEHBP members, refer to Monitoring Provider Exclusions.
The OPM, under the Inspector General U.S. Department of Health and Human Services (OIG-HHS), imposes suspension and debarment actions for entities contracted with the FEHBP. The current FEHBP suspended and debarred report is available at Healthnet.com. Registered providers can log into the provider portal to access the reports located under the regulatory section.
Providers on the FEHBP list will be terminated from all products, federal and non-federal. Additionally, a 12-month claims look-back review must occur for all identified participating and non-participating providers. FEHBP members identified through the claims review must receive notifications that they can no longer receive services from the provider.
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.
Exceptions must be documented in the claims processing system. Exceptions include but are not limited to:
- Urgent/emergent.
- Approved member exception.
- Inpatient stays within 30 days after suspension/debarment.
- Good faith in cases where member was not aware of the sanction.
- Suspended/debarred provider or owner/administrator in a non-debarred/suspended facility.
- Services by a non-debarred/suspended provider at a debarred/suspended group or clinic.