Very Brief Blog: Looking Up Providers Excluded from Medicare

Someone asked me which, if any, persons involved in Theranos had been excluded from participation in Medicare and Medicaid.   I don't know of any; I think exclusion usually follows a criminal conviction, and there are elaborate regulations for that.  (But see footnote*).  The statute is at SSA 1128, here.  See also 42 CFR 1003, revised 2016, here.  Mandatory exclusions include conviction for health care fraud.  Elective exclusions include loss of professional license related to professional performance or "financial integrity."

The good news is, HHS OIG makes it very easy to find exclusions.  There's a special webpage here.  There is a list of excluded individuals and entities (LEIE) which is a 70,000 line Excel file, here.  See also an online searchable database here.

Skimming the alphabetized LEIE spreadsheet from top down, there are 9 excluded persons at "accounting firms," and 90 excluded acupuncturists.

There are 108 excluded dental practices, followed by names of 1198 excluded dentists.   There are 613 excluded DME supply companies, and so on.  There are only about 45 excluded clinical laboratories or named employees of clinical laboratories.

You can also be excluded even if you are not a clinical provider like a doctor or nurse.  For example, there are ten excluded lawyers.   Persons excluded can't own or manage a business that serves Medicare or Medicaid. 

There are about 330 excluded "recipient/beneficiary" persons, followed by almost 200 persons excluded as "recruiters, cappers."

40 persons in the list of 70,000 are based in Abilene, Texas, and 146 reside in Des Moines, Iowa.  The rate is 2X higher in Des Moines (1 per 1500 residents vs 1 per 3000 in Abilene).  Glendale, CA falls in between (1 per 1750).

I don't think they cull the list for decedents, there are 138 persons listed with birthdates before 2019/03/22, so, more than 100 years old.   About 1000 names are persons born during the 1920s, the pending centenarians, including a podiatrist in Ohio and a pharmacist in St Louis.   The oldest physician listed was born in 1924 (103), the youngest 1987 (30).   There are 20 persons born in 1997, 1998, 1999.

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Note that in the database some physicians are listed as "Medical Practice, MD" and others as "Physician (MD/DO)."

Statistically, about 190 should share anyone's birthday (70,000/365); 5 share my exact birthdate.

One elective reason for exclusion is "claims for excessive charges or unnecessary services;" SSA 1128(b)(6).

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Owners of Theranos do not yet appear on the OIG Exclusion website.  However, they were excluded from: "participating in the operation of, or profit from, a laboratory for two years" beginning July 2016, the apparently expiring July 2018.  Here, final page, page 33.  This was a specific line-item exclusion but not a general exclusion from all services under CMS.