It is the policy of Johns Hopkins Health Plans to ensure compliance with federal and state mandates regarding reconciliation and payment of excluded providers, contractors, subcontractors, vendors, and Johns Hopkins Health Plans workforce members. 

Johns Hopkins Health Plans will do so through ongoing monitoring of:

1. All participating and non-participating providers submitting claims for reimbursement against Federal (System for Award Management and Office of Inspector General List of Excluded Individuals and Entities [LEIE]) and Maryland State exclusion/sanction lists.
2. All network providers at time of initial and re-credentialing cycles.
3. All contractors, subcontractors and vendors prior to contract execution.
4. All Johns Hopkins Health Plans workforce members at time of hire and monthly thereafter.

 It is Johns Hopkins Health Plans expectation that all providers, contractors, subcontractors, and vendors perform Federal and State exclusion checks on its employees.

Federal Health Care Program: For purposes of SSA §1128B(f), the term “Federal health care program” is defined as:

1. any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5, United States Code; or
2. any State health care program, as defined in section 1128(h).

State Health Care Program: For purposes of this section and sections 1128A and 1128B of the Social Security Act, the term “State health care program” is defined as: 

1. a State plan approved under title XIX, 
2. any program receiving funds under title V or from an allotment to a State under such title, 
3. any program receiving funds under subtitle I of title XX or from an allotment to a State under such subtitle, or 
4. a State child health plan approved under title XXI. 

Federal Mandatory Exclusion—The Secretary (DHHS) shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1128B(f)) of the Social Security Act.

1. Conviction of program-related crimes—Any individual or entity that has been convicted of a criminal offense related to the delivery of an item or service under title XVIII or under any State health care program.
2. Conviction relating to patient abuse—Any individual or entity that has been convicted, under Federal or State law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care item or service.
3. Felony conviction relating to health care fraud—Any individual or entity that has been convicted for an offense which occurred after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996, under Federal or State law, in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program (other than those specifically described in paragraph (1)) operated by or financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.
4. Felony conviction relating to controlled substance—Any individual or entity that has been convicted for an offense which occurred after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996, under Federal or State law, of a criminal offense consisting of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

Permissive Exclusion—The Secretary may exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1128B(f)).  Listed below is a partial list of where permissive exclusionary authority may be exercised.

1. Conviction relating to fraud
2. Conviction relating to obstruction of an investigation or audit
3. Misdemeanor conviction relating to controlled substance. 
4. License revocation or suspension.
5. Exclusion or suspension under federal or state health care program.
6. Claims for excessive charges or unnecessary services and failure of certain organizations to furnish medically necessary services. 
7. Fraud, kickbacks, and other prohibited activities.
8. Entities controlled by a sanctioned individual 
9. Failure to disclose required information 
10. Failure to supply requested information on subcontractors and suppliers 
11. Failure to supply payment information 
12. Failure to grant immediate access 
13. Failure to take corrective action 
14. Default on health education loan or scholarship obligations 
15. Individuals controlling a sanctioned entity
16. Making false statements or misrepresentation of material facts
17. Knowingly misclassifying covered outpatient drugs