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Case Dismissed: Enhanced Data Leads to HHS OIG Dropping an Exclusion Investigation


The Challenge

ProviderTrust identified an excluded individual in our client’s personal home care services business in 2017. Our solution matched and verified the exclusion using our smarter monitoring strategies: enhanced primary source data, industry-leading matching algorithms, and our human verification team for unique challenges. This particular exclusion was found based on our data models, despite receiving a different employee name than the one we matched on the primary source.    

About the Client

Our client is a national leader in post-acute home healthcare services in 16 states, providing comprehensive care, guidance, and support for a wide variety of needs, including short-term, complex, and chronic conditions.

The exclusion was published by the Texas Medicaid exclusion list in 2010 and was still active. We reported the findings, including the data enhancements used to verify the match, to our client in July 2017.

Our client began a review process to understand and document how the individual passed an original background check and how the exclusion was missed for so long. The individual had started full-time employment with our client in 2015, and it was discovered that pre-hire and monthly exclusion screening conducted before ProviderTrust’s Passport system was implemented were done only on the Name (First, Middle, and Last) given in the employee’s original employment application.

The matched exclusion published by Texas was an entirely different name— the individual had changed her name prior to applying for employment at one of our client’s facilities. 

Self Disclosure Process

After a comprehensive internal analysis and under the guidance of outside legal counsel, our client self-disclosed their findings to the state of Texas. When the excluded individual was terminated by our client, she applied for reinstatement to the OIG, even though the exclusion was published by Texas, not by the OIG LEIE. Her reinstatement application alerted the OIG to the exclusion and the self-disclosure, triggering an OIG investigation.  

Because the exclusion was only identified with enhanced data from ProviderTrust and was published under a different name, the state of Texas accepted a payback of monies and wages without a punitive multiple and closed the investigation. After Texas closed their investigation, the OIG sent a letter to our client closing the case and resolving the matter, with no further action recommended.   

Client Profile

  • 26,000+ employees (licensed and non-licensed)
  • 3,500+ licenses verified and monitored continuously
  • 16 states with facilities
  • 13 brands in client’s family of companies

Partnership Goals

  • Complete ongoing license and exclusion monitoring through an automated, easy-to-use application, providing exact matches to reduce the risk and inefficiencies within their current process.
  • Eliminate the challenge that our client faced in manually finding all available information within all of the licensing boards across the country and verifying each licensed professional.
  • Identify and correct employee license information, including license number, expiration date and issuing state or national certification boards currently maintained within their internal data repositories.
  • Identify and correct any inconsistencies with employee demographic information such as name, address or SSN, which could prevent accurate monitoring.
  • Create an authoritative data source where licenses can be stored and updated in real-time to prevent an unlicensed or uncertified person from working within the organization.

How We Helped

  • Conducted nationwide federal and state exclusion searches. With an employee population of this size, there will likely be exclusions that are found and need to be resolved. The previous vendor found very few potential matches, which should cause concern as to whether the search algorithm was sufficiently robust. This can be due to a limited matching algorithm or lack of data augmentation to find existing records.
  • Implemented our smarter monitoring protocol to determine the completeness of the employee demographics.
  • Provided client with updated employee demographic information, including name changes, address changes and inaccurate social security numbers.
  • Conducted license verification on all licensed employees at the primary source to create an accurate and complete license dataset for the client.
  • Leveraged ExclusionCheck as a screening tool for acquisition due diligence for employees of the acquired organizations.


Since implementing the Passport system in 2017, ProviderTrust has delivered:

  • 23 matched, verified exclusions across 26,000+ employees and 16 states
  • 429 state sanctions, or disciplinary actions, identified and verified across 9,800+ care providers
  • 382 licensure issues (missing, expired, revoked) verified across 3,500+ licensed care providers
  • 41 SSDMF results across 26,000+ employees

Final Review

ProviderTrust aims to deliver the most comprehensive and intelligent population monitoring solution for healthcare organizations. However, this particular story was a rare look for us into the state and OIG’s investigative process and how our smarter monitoring strategies play a significant role. In this case, our smarter monitoring and enhanced primary source data contributed directly to a proactive self-disclosure that resulted in Texas accepting a payback of Medicaid monies with no punitive multiple, and the OIG dropping their investigation and not pursuing additional punitive action.

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