Excluded but Still Prescribing

The Office of Inspector General (OIG) maintains a list of providers excluded from federal healthcare programs — typically due to convictions for fraud, abuse, or other offenses. Yet 82 of these providers appear in the 2023 Medicare Part D prescribing dataset.

What Does “Excluded” Mean?

OIG exclusion is serious. Excluded individuals are prohibited from participating in any federal healthcare program, including Medicare and Medicaid. Anyone who employs or contracts with an excluded individual for services billed to federal programs faces civil monetary penalties.

Types of exclusions include:

• Mandatory: Convictions for Medicare/Medicaid fraud, patient abuse, felony drug convictions
• Permissive: Misdemeanor fraud, license revocation, default on student loans, controlled substance violations

How Does This Happen?

Several explanations exist:

• NPI reuse or data lag — The CMS dataset and LEIE may not perfectly synchronize
• Prescriptions under old NPIs — Claims may be filed under a provider's NPI before exclusion took effect
• Reinstatement timing — Some providers may have been reinstated between the LEIE snapshot and the prescribing data period
• Genuine violations — Some excluded providers may genuinely be prescribing when they shouldn't be

The Accountability Gap

Regardless of the reason, the presence of excluded NPIs in active prescribing data highlights a system gap. If CMS cannot reliably cross-reference its own prescribing data against OIG's exclusion list, it raises questions about oversight effectiveness.