Am I required to disclose Board Disciplinary Actions even to Nevada Medicaid?
Disclosures to Other Entities
Every healthcare provider, regardless of profession, is required to disclose certain information to regulatory entities; both at the time of applying for a license or other credential, and after certain occurrences, such as another licensing entity taking disciplinary action or a criminal conviction. While providers are typically at least somewhat familiar with these disclosure requirements, many overlook disclosures that must be made to other entities, such as, facilities/hospitals, insurers, professional associations or specialty boards, and Medicaid and Medicare. Failure to properly make timely disclosures to these entities may result in the removal or denial of privileges or other credentials, or removal from payor panels.
State Medicaid
Requirements for state Medicaid program disclosures vary by each state, so providers enrolled with Medicaid in more than one state should review the rules and regulations particular to each state or seek legal advice. In Nevada, when submitting an application for provider enrollment, a provider must disclose information related to both state licensure actions and criminal convictions. Be aware that the Nevada Medicaid definition of “convicted” is similar to that utilized by Medicare (42 CFR 1001.2) which includes in the definition of “convicted” any action in which a post-trial or appeal is pending and whether the judgment of conviction is expunged. Additionally, both Medicare and Nevada Medicaid include deferred adjudications in their definitions of convicted. However, Nevada Medicaid also includes in the definition matters in which charges have been dismissed or set aside upon completion of the terms of a deferred adjudication. Due to the broad definition of “convicted” utilized by Medicaid, providers should be very diligent about reviewing provider enrollment applications before they are submitted to Medicaid; especially when prepared by a third party such as an office manager or credentialer.
Nevada Medicaid enrolled providers are required to disclose certain events to Medicaid within five working days, including, but not limited to, changes in “licensure status”, an “open/pending court case”, or an “open investigation by any law enforcement, regulatory or state agency.” Nevada Medicaid Services Manual (MSM) 103.3(B). This language is particularly difficult to navigate as the MSM does not define what “change in licensure status” is, or what they deem to be an open investigation by a regulatory agency. Most professional licensing boards in Nevada have statutes designating their investigations as confidential, making the requirement to proactively disclose an ongoing investigation to Nevada Medicaid problematic. Failure to timely report, however, is grounds for Medicaid to terminate a provider contract and impose a Tier-3, three-year sanction, excluding the provider from Medicaid.
Hospitals/Facilities
Providers that hold credentials at hospitals, and other facilities, should ensure that they are aware of any requirement to report certain occurrences to the facility’s medical staff office. This can include conditions or restrictions imposed by a licensing board, commencement of a civil action against the provider, or an arrest by law enforcement. As the bylaws of facilities can vary as to the requirements of what, and when a matter must be disclosed/reported, providers should remain aware of the requirements of any facility at which they hold privileges.
Specialty Boards/Professional Associations
Many specialty boards and professional associations require certain actions to be reported to them in accordance with their codes of conduct or ethics. Failure to report this information can result in the board or association initiating disciplinary procedures and is considered when reviewing the underlying issues giving rise to the reportable occurrence.
Commercial Payors
While not all payor contracts require reporting of licensure or other actions between recredentialing, providers should not assume that they are not required to report the information and should refer to their provider contract.
Regardless of whether a disclosure of a reportable occurrence is made, the matter must also be disclosed on any renewal or recredentialing application for the entity to which the disclosure was made.
When in doubt about if, and/or when, something must be disclosed and to whom, always seek legal guidance from a healthcare or professional licensing attorney.