A health care provider who does not participate in Medicaid may assume that being placed on Washington State’s Medicaid Provider Termination and Exclusion List has little practical significance. After all, if the provider does not intend to bill Medicaid, why would Medicaid exclusion status matter? That assumption can overlook significant consequences because placement on Washington’s Medicaid Provider Termination and Exclusion List can affect much more than a provider’s ability to participate in Apple Health.
Private insurers, managed care organizations, dental plans, employers, hospitals, and other health care entities may screen providers against government sanction and exclusion lists or incorporate exclusion-list status into their credentialing and participating requirements. As a result, a provider who has no intention of treating Medicaid patients may nevertheless find that a state Medicaid exclusion threatens participation in an entirely separate private insurance network. Chapman Law Group recently represented a Washington dentist in precisely that situation, ultimately securing his removal from the state Medicaid exclusion list and, as a result, preserving his participation in two private dental insurance networks.
The Washington State Health Care Authority (“HCA”), which administers Washington Apple Health, maintains a publicly available Provider Termination and Exclusion List. HCA explains that the list includes individuals and entities whose Medicaid participation has been terminated for cause, as well as Medicaid providers who have been excluded from participation. Providers terminated without cause are not included on the list.
HCA has broad authority under WAC 182-502-0030 to terminate a provider’s Medicaid enrollment for cause. The regulation identified numerous potential grounds for termination, including criminal convictions, fraud or abusive billing findings, dishonesty or other unprofessional conduct, exclusion from other government (i.e., federally-funded) health care programs, licensing and credentialing issues, failure to comply with Medicaid requirements, and other conduct that HCA determines is contrary to the interests of the agency or the health and safety of its clients.
For-cause termination can result in more than the loss of a provider’s ability to participate in Apple Health. Because HCA publicly identifies providers who have been terminated or excluded, the resulting exclusion list status can become relevant to other organizations that independently consider government sanctions or exclusions when making credentialing, contracting, or participation decisions. For that reason, even practitioners who do not rely on Medicaid reimbursement should understand both the basis for a Washington Medicaid exclusion and the potential consequences of appearing on the state’s exclusion list. In other words, the immediate question may concern Apple Health participation, but the provider should also consult with an experienced healthcare defense attorney to determine what an adverse Medicaid action could mean for every other important professional relationship.
For many practitioners, particularly solo practitioners and owners of small practices, the most significant consequence of a Medicaid exclusion may have nothing to do with Medicaid reimbursement.
Private provider agreements frequently impose credentialing and participation requirements that exist independently of Medicaid rules. Depending on the language of the particular agreement, inclusion on a government sanction, exclusion, termination, or preclusion list may provide a separate contractual basis for termination or other adverse action by the private payer. Credentialing organizations, hospitals, employers, and other entities may likewise consider government exclusion status when determining whether a practitioner remains eligible to participate.
This means that a practitioner who does not treat Medicaid patients cannot safely assume that a Medicaid exclusion is irrelevant. If participation in a major commercial network accounts for a significant percentage of the practice’s patients, a Medicaid exclusion that triggers termination from that network can have a far greater practical impact than the loss of Medicaid participation itself. It can disrupt established patient relationships, interfere with continuity of care, reduce patient access to the practitioner, and materially affect the financial stability of a solo or small-group practice.
Our firm recently represented a Washington dentist who had been placed on the Washington Medicaid Provider Termination and Exclusion List following a prior criminal conviction. The conviction concerned financial and tax-related conduct associated with the business operations of his dental practice, but it did not involve Medicaid billing, patient care, or participation in a federal or state health care program. The dentist completed his sentence years earlier, remained licensed, continued practicing dentistry, implemented additional financial and compliance safeguards, and continued serving his community.
Years after the original Medicaid action, however, his continued inclusion on the state exclusion list created an immediate problem with a private dental payer. The payer notified the dentist that his participation in two of its commercial dental networks was being terminated effective immediately based on his inclusion on a government sanction, exclusion, or preclusion list.
At that point, the Medicaid exclusion was no longer merely a historical enrollment issue. It threatened an active private payer relationship and, with it, the dentist’s continued ability to treat patients covered through those networks.
Chapman Law Group attorney Laith Quasem timely appealed the private payer termination, but we also addressed the problem at its source. We submitted a detailed written request to HCA seeking the dentist’s removal from the Washington Medicaid Provider Termination and Exclusion List. The submission addressed the history underlying the exclusion, the provider’s acceptance of responsibility and rehabilitation, the safeguards implemented since the underlying conduct, his lengthy professional history, his service to underserved communities, and letters of support from professionals familiar with his practice and character.
HCA presented the submission to its Medical and Dental Advisory Committee. The request was ultimately approved, and HCA submitted an update to remove the dentist from the Washington Medicaid Provider Termination and Exclusion List.
Importantly, removal from this list did not automatically re-enroll the dentist as an Apple Health provider. If he wishes to participate in Washington Medicaid in the future, he would still need to apply through the standard enrollment process and obtain approval. But immediate re-enrollment in Medicaid was not necessarily the immediate objective in this case. The immediate objective was to resolve the exclusion status that had become the basis for adverse action by a private payer.
After HCA approved the removal, we notified the private dental payer that the dentist was no longer on the exclusion list. The payer subsequently rescinded its termination of the dentist’s participation in both commercial networks, effective immediately, because the stated basis for termination was no longer applicable.
The result provides a useful illustration of why providers should not view Medicaid exclusion status in isolation. A government exclusion can have consequences throughout a practitioner’s professional relationships, and removing the underlying exclusion may resolve problems that extend well beyond Medicaid.
Providers should understand the distinction between removal from the Washington Medicaid Provider Termination and Exclusion List and re-enrollment in Apple Health. The two concepts should not be treated as interchangeable.
A practitioner may have a compelling reason to seek removal from the exclusion list even if the practitioner has no present desire to bill Medicaid. Removal can matter because of private payer contracts, credentialing requirements, employment relationships, hospital privileges, or other professional arrangements that consider government exclusion status. If the provider later decides to participate in Apple Health, the provider may still need to complete the applicable enrollment process and satisfy HCA’s requirements at that time.
That distinction can fundamentally change the strategy in an exclusion matter. The question is not necessarily whether the provider wants to become a Medicaid provider again. The more immediate question may be whether continued inclusion on a publicly available government exclusion list is creating collateral consequences elsewhere in the provider’s professional life.
The Washington regulations governing for-cause termination do not provide a detailed reinstatement standard comparable to some federal exclusion procedures. Federal Medicaid regulations nevertheless contemplate reinstatement following a state-agency exclusion when the state affords excluded providers that opportunity. Under 42 C.F.R. §§ 1002.214 and 1002.215, reinstatement is tied principally to whether the conduct that formed the basis for the original exclusion has recurred and whether the state agency is “reasonably certain” that it will not recur. The framework also permits consideration of the provider’s conduct following exclusion and certain outstanding financial obligations.
The appropriate showing will depend heavily on the reason for the original exclusion. Passage of time alone may not be enough. A persuasive request should explain what happened, what the provider has done since then, why the circumstances that led to the exclusion will not recur, and why continued exclusion is no longer necessary to protect the Medicaid program.
For example, when financial misconduct contributed to the exclusion, evidence of enhanced financial oversight, independent accounting, separation of responsibilities, and other safeguards may be particularly important. Where clinical, documentation, or compliance issues were involved, the provider should be prepared to explain the policies, procedures, training, or other changes implemented to address those concerns. Evidence of continued professional licensure, an appropriate subsequent professional record, community service, care for underserved populations, and credible letters of professional support may also strengthen the presentation depending on the circumstances.
The objective should generally not be to minimize the original conduct or simply argue that HCA should never have taken action. Where the provider accepts responsibility for the circumstances that led to exclusion, a more productive approach may be to demonstrate why those circumstances no longer justify continued exclusion today.
When a private payer takes action under a provider agreement because the practitioner appears on a state Medicaid exclusion list, removal from that list may not be the provider’s only avenue for relief. Depending on the language of the provider agreement, the provider may have contractual appeal rights and may be able to challenge whether the exclusion satisfies the agreement’s stated grounds for termination, whether the payer followed the required procedures, or whether other contractual protections apply. Those rights should be carefully reviewed and, where appropriate, preserved.
At the same time, when the underlying exclusion itself can be addressed, our preferred approach is generally to pursue the issue at its source rather than rely exclusively on arguments over the private payer’s contractual response. Successfully removing the provider from the government exclusion list can eliminate the very condition on which the private payer acted. The recent matter handled by our firm illustrates the value of that approach because we timely appealed the private dental plan’s termination while simultaneously seeking removal from Washington’s Medicaid exclusion list. Once HCA approved the removal, the private payer rescinded its termination because the stated basis for taking action no longer applied.
This does not mean that every Medicaid exclusion can be removed or that a provider should forego available contractual appeal rights while seeking removal. Depending on the circumstances and applicable deadlines, both avenues may need to be pursued simultaneously. The broader strategic principle is that when a private payer’s action derives from an underlying government exclusion, counsel should evaluate both the resulting private payer action and whether the underlying government action can itself be resolved.
Washington health care providers should not assume that Medicaid exclusion status matters only to practitioners who bill Apple Health. The public nature of the Provider Termination and Exclusion List, combined with independent credentialing and contractual requirements imposed by private health care organizations, means that a Medicaid exclusion can follow a practitioner into professional relationships that otherwise have nothing to do with Medicaid.
This is particularly important for solo practitioners and small practices, where termination from a significant commercial network can have an immediate effect on patients and practice operations. A provider who receives notice of a for-cause Medicaid termination should therefore evaluate the broader consequences before deciding that the matter is unimportant simply because Medicaid participation is not a business priority. Likewise, a provider who has remained on the exclusion list for years should consider whether changed circumstances, rehabilitation, remediation, or other developments provide a basis to seek removal.
Our recent matter illustrates the practical importance of looking beyond Medicaid enrollment itself. The dentist did not need automatic re-enrollment in Apple Health to accomplish his immediate objective. He needed to resolve the underlying exclusion that had become the basis for termination from his private dental networks. Once HCA approved his removal from the list, the predicate for the private payer’s action disappeared, and the payer rescinded the termination.
For practitioners facing similar circumstances, the lesson is that a Medicaid exclusion should be evaluated for what it is and for what it may cause elsewhere. Sometimes the most important reason to seek removal from a Medicaid exclusion list is not to return to Medicaid at all, but to protect the provider’s patients, practice, and other professional relationships. If you are on the Washington Medicaid Termination and Exclusion list, reach out today by filling out the contact form below to see how Chapman Law Group can help you.
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Laith Quasem
Associate Attorney
Professional Licensing & Regulatory Affairs, Healthcare Compliance, Federal Criminal Defense
Seattle Office (Satellite)
Washington
Phone: (877) 234-5911
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