At ProviderTrust, we spend a lot of time analyzing data because we love recognizing and explaining unique patterns to help tell a story. We are in the monitoring and verification business and know how metrics matter to a wide variety of healthcare professionals. We do our best to try and break down big pieces of data from multiple sources and tie ideas together for multiple department discussion.

One of the things that matters a lot to us, and hopefully you as well are healthcare exclusions. The strings attached with exclusions can vary as far as the Grand Canyon. Sometimes, individuals or entities may be excluded for what is considered to be a minor misstep or mistake. Other times, the situation(s) are more severe and have a major impact on people and places in a negative way.

Statistically speaking, we thought we would take a look at the volume of exclusions and break them down by authorities (exclusion type). Our list may not be as exciting as David Letterman’s Top 10 but interesting for some of us. Hope you enjoy! 

Top 7 OIG Reasons for OIG LEIE Exclusions (by volume): 

* Last updated March 6, 2018

Section Exclusion Authority Number of Individuals 

or Entities

1128b4 License revocation, suspension or surrender 30,036
1128a14 Conviction for program-related crimes 19,694
1128a2 Conviction relating to patient abuse or neglect 6,611
1128a3 Felony conviction relating to healthcare fraud 3,832
1128a3 Felony conviction relating to healthcare fraud 3,832
1128a4 Felony conviction relating to controlled substances 2,581
1128b14 Default on health education loan or scholarship 2,283
1128b8 Entities controlled by a sanctioned individual 1,488

Healthcare Exclusion Interesting Facts

  • 36,480 of the total OIG LEIE exclusions are permissive (53%)
  • 48% of exclusions are due to a license revocation or termination
  • 37,913 state exclusions are not on the OIG LEIE (57%)
  • 2,283 individuals excluded due to defaulting on a student loan

Did you know? State MFCUs are required to report excluded, suspended, or disqualified individuals or entities to the OIG within thirty (30) days? This is done to ensure that OIG can determine if it needs to add those persons or entities to the OIG List of Excluded Individuals and Entities (LEIE) list for mandatory or permissive purposes.   Here’s the dilemma…many states are lagging big time. What you don’t know about someone at the state level could really up the ante for your risk if you aren’t careful by checking each state Medicaid exclusion list. Below you can find the states that have the highest amount of state exclusions which have not made it to the LEIE.

Top 5 States with the Most Medicaid Exclusions Not Found on LEIE

  1. California
  2. Florida
  3. Illinois
  4. Michigan
  5. Maryland

ProviderTrust Compliance Healthcare Index Report

Each quarter, our team helps show the complex relationship between state Medicaid excluded individuals and entities, and their relationship to OIG LEIE. We also break down key statistics and walk through exclusion data state by state so you can keep up with where you may be providing care. Take a look below!

 

ProviderTrust Compliance Healthcare Index Report

What You Need to Know About Exclusions

  • Exclusions are numerous and of concern for any healthcare organization that is billing or being reimbursed for federal healthcare dollars (Medicare, Medicaid, CHIPS, TriCare).
  • There are exclusions at over 43 data sources at the federal and state level
  • The OIG exclusions total approximately 70,000 individuals and entities and the state exclusion account for just shy of another 70,000 exclusions. When you add the number of SAM.gov healthcare exclusions, the total exclusion dataset amount to over 200,000 excluded individuals and entities.
  • The most common OIG reason for exclusion is due to a revocation or termination of a professional license.  
  • Finally, non-licensed owner, officers, managers and administrative personnel can also be excluded.  

Best practice is to monitor all sources each month for all healthcare employees, contractors, and vendors. At ProviderTrust, we pride ourselves on finding solutions to this complicated search process with automation and data team that can’t be beaten! 


Check out our latest resources! License Monitoring eBook


Written by Michael Rosen, ESQ

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc 500 Award and Nashville Chamber of Commerce Small Business of the Year.

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