Excluded

An Exploration of the LEIE

Overview

• What?
• Why?
• Explore
• Places to Start
• Heatmaps
• LEIE Alternatives
• Observations
• Questions

What?

“OIG has the authority to exclude individuals and entities from Federally funded health care programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud. Those that are excluded can receive no payment from Federal health care programs for any items or services they furnish, order, or prescribe. This includes those that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).”[1]

LEIE

• List of Excluded Individuals and Entities
• Maintained by OIG
• 78k obs
• 18 vars
• 1977 - 2023
• 150/mon
• updated monthly

Waivers

• Waiver when
  • sole provider;
  • essential service; and
  • community hardship

An individual or entity excluded under sections 1128(a)(1), (a)(3) or (a)(4) of the Act may be eligible for a waiver only when the excluded individual or entity is the sole community physician or the sole source of essential specialized services in a community AND the exclusion would impose a hardship on beneficiaries (as defined in section 1128A(i)(5) of the Act) of that program. An individual or entity excluded under section 1128(a)(2) of the Act as a result of a conviction related to patient abuse or neglect is not eligible for a waiver. See 42 CFR 1001.1801(a)-(b).[1]

Reinstatement

Reinstatement if

• after exclusion period;
• after license reinstated; and
• no patient neglect or abuse

“Individual or entity must apply for reinstatement and receive written notice from OIG that reinstatement has been granted.”[1]

Mandatory Exclusions

SSA 1128:

• section(a) Mandatory (4)
  • program-related crime
  • patient abuse
  • felony healthcare fraud
  • controlled substance

Excluded for “Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.”[1]

Permissive SSA 1128

• section(b) permissive (17)

• misdemeanor convictions related to health care fraud other than Medicare or a State health program;
• fraud in a program (other than a health care program) funded by any Federal, State or local government agency;
• misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity;
• provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements;
• defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee.[1]

Permissive SSA 1156

• services must be
  • economical;
  • medically necessary; and
  • of sufficient quality; and if
• provider fails in
  • substantial number of cases substantially to comply; or
  • grossly and flagrantly violated then
• Secretary may exclude

Exclusions by Statute

statute	exclusion	description	n_count
1128b4	Permissive	License revocation or suspension	31084
1128a1	Mandatory	Conviction of program related crimes	23109
1128a2	Mandatory	Conviction for patient abuse	7449
1128a3	Mandatory	Felony conviction for healthcare fraud	4987
1128a4	Mandatory	Felony conviction for controlled substance	3140

Consequences

• No participation
• No payments
• No hiring

Variables

lastname	specialty	city	reindate
firstname	upin	state	waiverdate
midname	npi	zip	wvrstate
busname	dob	excltype
general	address	excldate

“Those that are excluded can receive no payment from Federal health care programs for any items or services they furnish, order, or prescribe.”[1]

Why care about the LEIE?

Machine Learning Pipeline

1. Find data (predictors & outcome)
2. Create features
3. Partition and stratify
4. Choose models
5. Resample
6. Tuning
7. Measure performance
8. Test

Machine Learning Healthcare Fraud

Part B data <– LEIE by NPI

ML Healthcare Fraud Network Graph

Challenges - Class Imbalance

• Herland (2020)
• 4 years Part B
• 1.1 million physicans
• 1,312 fraud
• 10 + per 10,000 physicians

Strategies

• Random undersampling (90/10 optimal)
• Random oversampling
• Hybrid
• Match LEIE w/ NPI?

Corpus/Matrix Size

Corpus/Matrix Example

Explore

Missing Identifiers by Year

Individuals Excluded by Statutory Provision

Exclusions by Statutory Provision

Average Monthly Exclusion

Excluded Physicans by Category

Exclusions by Category

Exclusions by General Category

Exclusion by Type

Exclusion by Type and Category

Physicians Excluded by Specialty

Variable Importance Plot

Places to Start

California

CMS vs. California

New York

CMS vs New York

Texas

CMS vs. Texas

Initial Effort

Three years of internal medicine from TX, CA, NY, FL, yielded 89k observations, 2500+ columns, and 42 fraud cases for a 5 per 10,000 result.

Heatmaps

Exclusion by State and Statute

Exclusion by State and Year

Exclusion to General

Physician Specialty to Exclusion

LEIE Alternatives

CMS Exclusions

link

CMS Preclusions

link

NPDB

link

Observations

• Total annual exclusions are declining
• Percent of excluded with NPIs is increasing
• UPIN converted to NPIs around 2009
• Medical practice –> to Doctor in 2009

Questions

• Can the exclusions be scaled?
• What exclusion types are indicative of fraud?
• Are there strategies to boost NPI matches?
• Will the LEIE remain relevant in future fraud detection?

Bibliography

[1]

“Exclusions | Office of Inspector General | U.S. Department of Health and Human Services.” Accessed: Aug. 30, 2023. [Online]. Available: https://www.oig.hhs.gov/exclusions/index.asp