Client Alerts & Insights
OIG Report – The Low Hanging Fruit – Excluded Providers in Medicaid Managed Care Plans
October 4, 2012
On September 27, 2012, the US Department of Health and Human Services Office of the Inspector General’s (“OIG”) Office of Evaluation and Inspections a report (OEI-07-09-00632) entitled “Excluded Individuals Employed by Providers Enrolled in Medicaid Managed Care Entities”.
Identifying excluded individuals that are connected to the Medicare and Medicaid programs has traditionally been low-hanging fruit for the government. It is an easy issue to prove and the recoveries can be significant. This study is just one more example of the OIG’s focus on this area that is easy to enforce.
This most recent OIG study looked at employees at providers participating in Medicaid managed care plans, which are federally funded health care programs. The OIG focused on these providers because they are not under direct oversight by the state Medicaid programs and it wanted to determine if the managed care provider networks are vulnerable to excluded providers.
The OIG reviewed an employee roster of 248,869 individuals from sampled providers. Of those individuals it identified 16 individuals who were excluded among the employees of 14 sampled providers. While the amount of excluded individuals identified may seem small in contrast to the sample reviewed, providers have to understand the risk involved.
The OIG unfortunately did not quantify the federal health care program dollars that could be at risk for the 16 individuals identified. However, 8 of the were direct care providers. Depending upon the circumstances, if the direct-care provider has Medicare/Medicaid revenue associated with them, such as a physician, the dollars at risk can be significant. As a result, providers involved in any federal health care program, whether manager care or otherwise, need to be vigilant and have internal processes designed to prevent and detect excluded individuals. While this issue is an easy target for the government, it is also an easy opportunity for providers to avoid liability by checking the exclusion lists on a regular basis.
You can find a copy of the OIG report here —> OEI-07-09-00632
Additional Information
For more information on the OIG Report, Medicare Program Integrity initiatives or related issues in the health care industry in general, please contact Ari Markenson or any member of Benesch’s Health Care Department:
Ari J. Markenson at 914.682.6822 or amarkenson@beneschlaw.com
Benesch’s Health Care Practice Group
Cleveland
Gregory Binford at 216.363.4617 or gbinford@beneschlaw.com
Harry Brown at 216.363.4606 or hbrown@beneschlaw.com
W. Clifford Mull at 216.363.4198 or cmull@beneschlaw.com
Daniel O’Brien at 216.363.4691 or dobrien@beneschlaw.com
Alan Schabes at 216.363.4589 or aschabes@beneschlaw.com
Columbus
Frank Carsonie, Chair at 614.223.9361 or fcarsonie@beneschlaw.com
Janet Feldkamp at 614.223.9328 or jfeldkamp@beneschlaw.com
Martha Sweterlitsch at 614.223.9367 or msweterlitsch@beneschlaw.com
Latest News
The Coming State-Law Litigation Wave of 2026-27: “Subscription Trap” Class Actions
The subscription economy keeps growing—and so does the wave of class-action litigation targeting it. While the FTC’s regulatory efforts have drawn headlines, private class actions under state laws pose an even greater exposure risk.
Updates to Fees and Grace Periods for Nonimmigrant Visas
Starting September 9, 2026, the 9-11 Response Biometric Entry-Exit Fee will apply to H-1B and L-1 extension petitions filed by employers subject to the fee. Prior to the new rule, the fee was only required for (1) initial grant of status to a foreign national seeking H-1B or L-1 status and (2) a change of employer in the same status.
Third Circuit Decision Reshapes Creditor Standing in Successor Liability Disputes
The Third Circuit recently held that when determining whether a successor liability claim belongs to a bankruptcy estate, the key question is whether the claim seeks to remedy harm suffered by all creditors collectively or a unique injury suffered by a specific creditor. The fact that creditors may be permitted to bring the claim outside of bankruptcy is not, by itself, determinative.
CMS Proposes Sweeping Restrictions on Remote Patient Monitoring: The Outsourcing Ban, Reimbursement Revaluation and Potential Code Consolidation in the CY 2027 Physician Fee Schedule Proposed Rule
CMS’s CY 2027 Proposed Rule would significantly restrict Medicare reimbursement for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM), including banning outsourced clinical staffing, adding new patient-relationship and initiating-visit requirements, reducing certain reimbursement rates, and exploring consolidation of existing billing codes.