27 Ways For Providers To Get Kicked Out Of NJ Medicaid

There are at least 27 different basis for exclusion or denial of provider enrollment application in the New Jersey Medicaid Program.  Some are not so obvious.

Some of the more self-evident reasons for provider exclusion from the Medicaid program include:

  • exclusions from participating in Medicare or other federally funded program;
  • exclusion from participating in any state-funded medical assistance and/or health services program of another state;
  • violation of the Federal or state antitrust statutes or the anti-kickback provisions;
  • submitting false or fraudulent claims for services or merchandise; and
  • conviction of a crime involving moral turpitude.

Providers might be surprised to learn some of the lesser known reasons that could be used as a basis for exclusion:

  • violations of any laws governing hours of labor, minimum wage standards, prevailing wage standards, discrimination in wages or child labor;
  • violations of any laws, regulations or code of ethics governing the conduct of occupations or professions or regulated industries;
  • violations of the Law Against Discrimination;
  • failure to provide and maintain quality services to Medicaid beneficiaries within accepted medical community standards as determined by a body of peers;
  • breach of the terms of the Medicaid provider agreement entered into with Medicaid;
  • submitting false information for the purpose of obtaining authorization requirements;
  • failure to provide to the Medicaid Agent or DMAHS records of services provided to or payments made on behalf of Medicaid beneficiaries; and
  • rebating or accepting a fee or portion of a fee or charge for a Medicaid beneficiary referral.

Additional grounds for provider exclusion can be found at N.J.A.C. 10:49-11.1(d)(1)-(27). These factors can also be the basis of denial of provider enrollment or revalidation in the Medicaid Program.

If you have questions regarding participating in New Jersey Medicaid program, program exclusion, or need other legal assistance, please contact us.