Medi-Cal law, Welfare and Institutions Code (W&I Code), sections 14043.6 and 14123, mandate that the Department of Health Care Services (DHCS) suspend a Medi-Cal provider of health care services (provider) from participation in the Medi-Cal program when the individual or entity has:

• Been convicted of a felony;
• Been convicted of a misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service;
• Been suspended from the federal Medicare or Medicaid programs for any reason;
• Lost or surrendered a license, certificate, or approval to provide health care; or
• Breached a contractual agreement with the Department that explicitly specifies inclusion on this list as a consequence of the breach.

Suspension of Entities Submitting Claims for Suspended Providers

Suspension is automatic when any of the above events occurs, and suspended Medi-Cal providers will not be entitled to a hearing under the California Administrative Procedures Act.

Services rendered, prescribed or ordered by a suspended Medi-Cal provider shall not be covered by the Medi-Cal program while the suspension is in effect. California Code of Regulations, title 22, section 51303, subdivision (k), provides that at least fifteen (15) days written notice be given to all affected providers. This list constitutes such written notice. Although the period of suspension may have expired, reinstatement rights are not automatic. The provider must petition for reinstatement and re-enroll with DHCS before being reimbursed for services rendered. Providers suspended as a result of a Medicare action must appeal through the Medicare office before applying for re-enrollment with Medi-Cal.

In accordance with W&I Code, section 14043.61, subdivision (a), a provider of health care services shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from the Medi-Cal program for the services, goods, supplies or merchandise provided, directly or indirectly to a Medi-Cal beneficiary, by an individual or entity that is suspended, excluded or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi-Cal program and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List (S&I List) published by DHCS to identify suspended and otherwise ineligible providers, or any list published by the federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the federal Medicare and Medicaid programs, to identify suspended, excluded or otherwise ineligible providers.

Examples of providers who need to be aware of the provisions of this law, and could be suspended if violating the law are:

1. Billing services that submit claims for Medi-Cal providers who are suspended;
2. Pharmacies that fill prescriptions and bill for services prescribed by a suspended provider;
3. Providers who bill for services under referral or prescription of a provider who is suspended;
4. Providers who employ and submit claims for the services of an individual who is a suspended provider;
5. Physician groups, clinics and institutions that employ and submit claims for the services of an individual who is a suspended provider;
6. Any individuals or entities that enter into a business arrangement and submit claims for or in conjunction with an individual or entity that is suspended.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities. Cross-referencing both lists is recommended to help identify providers who have already been suspended or sanctioned. The S&I List is not all inclusive. Temporary sanctions against providers are not included on the web sites. Temporary sanctions that may be imposed include temporary suspensions, withhold of payments and deactivation.