Provider Sanctions

In the event a provider is deemed to be in violation of a provider manual, state statute, state regulation or federal regulation, MMAC is responsible for imposing a sanction on the provider. In determining the appropriate sanction MMAC takes into account the following aggravating and/or mitigating circumstances in accordance with 13 CSR 70-3.030.

The specific sanction imposed can be any of the following:

• Education
• Overpayment
• Prepayment Review
• Payment Suspension
• Suspension
• Termination

Learn more about Missouri Medicaid Program Regulations

Medicaid Terminations

The Missouri Medicaid program wants to ensure that the best medical professionals participate in the Medicaid program. When the program finds good reason that a provider should no longer be eligible to participate, they are placed on a list of terminated providers. To access this list, click on the link below, and read the disclaimer regarding the list of terminations.

List of Terminations:

• View A complete list of providers who have had their enrollment in the Missouri Medicaid program terminated since 2/3/2011 and the reasons for the termination.  Please note that not all providers who have had their enrollment terminated since 2/3/2011 are on the list.  The Missouri Medicaid Audit and Compliance Unit, rather, terminated the providers on the list for conduct which was deemed potentially detrimental to the Missouri Medicaid program. This list is reviewed monthly for updates.

Additional Resources for Provider Information:

1. Health and Human Services. This Web site, hosted by the Office of the Inspector General within the federal Department of Health and Human Services (HHS), outlines their exclusion program and includes a searchable version of their List of Excluded Individuals/Entities (LEIE).
2. Government Services Administration. This Web site is provided as a public service by the Government Services Administration for the purpose of efficiently and conveniently disseminating information on parties that are excluded from receiving federal contracts, certain subcontracts, and certain federal financial and non-financial assistance and benefits, called the System for Award Management (SAM).

Information About Terminated Individuals or Entities

This Web site contains lists of individuals or entities whose participation in the Missouri Medicaid program has been terminated under the provisions of  13 CSR 70-3.030 .

Using the Lists of Terminated Individuals or Entities

The Affordable Care Act (ACA) requires that all physicians or other professionals who order or refer services for which a claim will be submitted to the Medicaid program must be enrolled as participating providers (see 42 CFR 455.410 (b)). Therefore, any un-enrolled provider, including any provider who is terminated from the Medicaid program for any reason, is not allowed to furnish, order, prescribe, or make referrals for services for which claims to the Medicaid program will be generated.

Use of this list will help providers avoid submitting claims for medical care, services, and/or supplies that are ordered or prescribed by individuals or entities who are not authorized to submit such orders. Enrolled providers should verify that the orderer has not been terminated before filling an order or prescription. If the orderer’s or prescriber’s name appears on the List of Terminated Individuals or Entities, Medicaid should not be billed for the care, services, or supplies ordered, prescribed, or provided by that person or entity.

Any claim submitted for medical care, services, or supplies ordered/prescribed by any providers appearing on the List of Terminated Individuals or Entities may be denied, and the enrolled provider dispensing prescriptions or filling orders may be held responsible for repayment of any payments made by the Medicaid program under these circumstances.

For orders or prescriptions requiring prior approval or prior authorization, it should be noted that the receipt of an approval or authorization is not a guarantee of payment. Payment is subject to a patient’s eligibility and compliance with all applicable statutes and policies.

Providers are reminded that part of an effective compliance program should include checking the sanction list at least on a monthly basis. This will make providers aware of any terminations that may have taken place since the last search.

Any provider who has been terminated on or after January 1, 2011 from Medicare or from the Medicaid program or CHIP of any other state may not be enrolled or reinstated in the Missouri Medicaid program (42 CFR 455.416 (c)).