OIG Exclusions

The OIG Exclusion database: the government's naughty list for Medicare and Medicaid. If you aren't familiar with the OIG database, it's the list of people and businesses that the government has decided may no longer bill Medicare and Medicaid. It's not a great list to be on.

It's been more than a year since I've looked at it so it's time. Let's take a quick dumpster dive into this thing and see what's going on!

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You can see that in 1996, the OIG really started going after both individuals and businesses. By 2000, the enthusiasm for business starts to wain and there's another big uptick in individuals. in 2008 OIG takes a breather for 2-3 years and then more than makes up for lost time starting in 2011.

Exclusion Reasons

Eight exclusion reasons account for nearly 96% of the exclusions:

Percent SSA Reason
43.9% 1128.b.4 License revocation or suspension. Minimum Period: No less than the period imposed by the state licensing authority.
26.7% 1128.a.1 Conviction of program-related crimes. Minimum Period: 5 years
9.5% 1128.a.2 Conviction relating to patient abuse or neglect. Minimum Period: 5 years
5.2% 1128.a.3 Felony conviction relating to health care fraud. Minimum Period: 5 years
3.6% 1128.a.4 Felony conviction relating to controlled substance. Minimum Period: 5 years
3.5% 1128.b.14 Default on health education loan or scholarship obligations. Minimum Period: Until default has been cured or obligations have been resolved to Public Health Service's (PHS) satisfaction.
2.2% 1128.b.8 Entities controlled by a sanctioned individual. Minimum Period: Same as length of individual's exclusion.
1.1% 1128.b.1 Misdemeanor conviction relating to health care fraud. Baseline Period: 3 years

Almost 44% of the exclusions are due to exclusions by the state licensing authority. Unfortunately we can't get more detail on 1128.b.4. It would be interesting to see the nature of the infraction.

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The map above shows the number of exclusions as a percentage of the number of health care workers in the state. Vermont stands out having a rate that is nearly twice as high as any other state, but the overall number of exclusions is still low at 350.

Arizona comes in second withe an exclusion rate of 0.7% of all healthcare workers in the state. Meanwhile, Delaware and Hawaii have essentially no exclusions.

This data is constantly updated and although it's extra work you don't really want to be doing, if you are involved in billing for Medicare and Medicaid you need to occasionally check your employees versus this list. 

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Waivers & Reinstatements

Once you land on the OIG list, it's pretty difficult to get back off. 

There are 66,042 businesses and people on the list. There are zero reinstatements and 14 waivers.  I've mapped the waivers for you.

Contact me if you want to automate your employee checking versus the OIG exclusion database.