{ "study": { "slug": "federal-state-exclusion-gap-2026", "title": "The exclusion gap: federal screening misses most state Medicaid bars", "standfirst": "Federal-only exclusion screening misses most state Medicaid exclusions: of 4,851 NPI-identified providers excluded across ten state Medicaid programs, 3,117 — 64.3% — carry no record on the federal OIG LEIE. An organization checking the federal list alone clears nearly two in three state-barred providers as clean.", "desk": "financial-distress", "article_type": "Original Research", "published": "2026-06-15", "issue": 54, "doi": "10.5072/fonteum/federal-state-exclusion-gap-2026", "url": "https://fonteum.com/research/federal-state-exclusion-gap-2026", "methodology_version": "exclusion-gap/v1" }, "data_as_of": "2026-06-15", "datasets": [ { "slug": "oig-leie", "name": "OIG LEIE", "publisher": "HHS OIG — List of Excluded Individuals/Entities", "upstream_url": null } ], "key_findings": [ { "number": "64.3%", "finding": "of NPI-identified providers excluded by a state Medicaid program (3,117 of 4,851) carry no record on the federal OIG LEIE", "dataset": "state-exclusions" }, { "number": "3,117", "finding": "state-excluded providers across ten states that federal-only OIG LEIE screening would clear as having no exclusion on file", "dataset": "state-exclusions" }, { "number": "59.8%", "finding": "New York's invisibility share — 1,347 of 2,254 NPI-identified state-excluded providers are absent from the federal LEIE", "dataset": "state-exclusions" }, { "number": "15,293", "finding": "additional in-force state exclusion records carry no NPI at all — unmatchable to the federal list by identifier, reported separately", "dataset": "state-exclusions" } ], "faqs": [ { "q": "What is the federal–state exclusion gap?", "a": "It is the share of providers excluded by a state Medicaid program that carry no matching record on the federal OIG List of Excluded Individuals and Entities (LEIE). Across ten state Medicaid programs, 3,117 of 4,851 NPI-identified state-excluded providers — 64.3% — are absent from the federal list. An organization that screens the federal LEIE alone never sees them." }, { "q": "Why would a provider be excluded by a state but not by the federal OIG?", "a": "State Medicaid agencies run their own exclusion programs and act on their own authority and timeline. A state can bar a provider for a Medicaid-specific reason — a state license action, a state fraud referral, an administrative termination — without an OIG exclusion ever following. The OIG can adopt many of these under its permissive §1128(b) authority, but adoption is discretionary and lagged, so a large standing set of state bars never reaches the federal list." }, { "q": "How many state-excluded providers does federal-only screening miss?", "a": "Among providers with an NPI, 3,117 of 4,851 — 64.3% — across the ten live states. New York alone accounts for 1,347 of them, Pennsylvania 569, and Ohio 363; the seven newer states add the rest. These are the providers a federal-LEIE-only check would return as having no exclusion on file." }, { "q": "Does the gap change if you count federal exclusions that were later reinstated?", "a": "No. The OIG removes reinstated parties from the published LEIE, so the federal file is already a current-active snapshot. The 64.3% figure is identical whether or not an in-force filter is applied on the federal side." }, { "q": "What about state exclusions with no NPI?", "a": "A further 15,293 in-force state exclusion records carry no NPI at all. They cannot be matched to the federal list by identifier, so NPI-based federal screening cannot reach them either. They are excluded from the matchable denominator and reported separately rather than guessed at by name." }, { "q": "Which states are included, and why not all 50?", "a": "Ten states publish a usable Medicaid exclusion file and are ingested: New York (OMIG), Ohio (ODM), Georgia (DCH Office of Inspector General), Pennsylvania (DHS), North Carolina (DHHS), Maryland (MDH), Washington (HCA), Iowa (Medicaid), Mississippi (DOM), and Montana (DPHHS). State Medicaid exclusion data is fragmented and inconsistently published, so coverage expands one primary source at a time." }, { "q": "Can I reproduce these numbers?", "a": "Yes. Every figure is a direct join between the public state_exclusions and oig_leie_exclusions tables on NPI. The exact SQL is published in the reproducibility block below; each count resolves to specific rows in specific frozen snapshots, and no match is ever inferred from a name." } ], "citation": { "apa": "Fonteum Research. (2026, June 15). The exclusion gap: federal screening misses most state Medicaid bars. Fonteum Research, Issue 54. https://doi.org/10.5072/fonteum/federal-state-exclusion-gap-2026", "url": "https://fonteum.com/research/federal-state-exclusion-gap-2026" }, "reproducible_sql": "-- The federal–state exclusion gap — fully reproducible query.\n--\n-- Question: how many providers excluded by a STATE Medicaid program are\n-- invisible to FEDERAL-only screening — i.e. carry no record on the OIG LEIE?\n--\n-- Sources:\n-- public.state_exclusions — State Medicaid exclusion lists (the State\n-- Exclusion Ring: ten states — NY OMIG, PA DHS,\n-- OH ODM, IA, MD, WA, NC, MS, MT, GA DCH-OIG).\n-- Public, read-only.\n-- public.oig_leie_exclusions — OIG List of Excluded Individuals/Entities,\n-- federal monthly bulk download, release\n-- 2026-05-08, 68,055 active records (7,025 with\n-- an NPI). Public, read-only.\n--\n-- Join key: NPI only (10-digit, btrim). We never match on name — a name match\n-- is not a defensible identity assertion, so rows with no NPI are excluded from\n-- the matchable denominator and reported separately (see no-NPI query below).\n--\n-- \"In force\" mirrors the production exclusion lookup (src/lib/exclusions): a row\n-- is in force when reinstatement_date IS NULL OR reinstatement_date > today.\n-- Applied to BOTH tables. Date basis: current_date (2026-06-15 at publish).\n--\n-- Every headline figure in the study resolves to one of the rows below.\n\nWITH se_inforce AS (\n SELECT state,\n nullif(btrim(npi), '') AS npi\n FROM public.state_exclusions\n WHERE reinstatement_date IS NULL OR reinstatement_date > current_date\n),\nfed_inforce AS (\n -- Distinct federal NPIs in force. (The LEIE drops reinstated parties from the\n -- published file, so this set equals \"any LEIE row by NPI\" — the 64.3% gap is\n -- identical whether or not the in-force filter is applied on the federal side.)\n SELECT DISTINCT btrim(npi) AS npi\n FROM public.oig_leie_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > current_date)\n),\nstate_npi AS ( -- distinct NPI-identified, in-force provider per state\n SELECT DISTINCT state, npi FROM se_inforce WHERE npi IS NOT NULL\n),\nper_state AS (\n SELECT s.state,\n count(*) AS matchable_providers,\n count(*) FILTER (WHERE f.npi IS NULL) AS federally_invisible\n FROM state_npi s\n LEFT JOIN fed_inforce f USING (npi)\n GROUP BY s.state\n),\noverall_npi AS ( SELECT DISTINCT npi FROM se_inforce WHERE npi IS NOT NULL ),\noverall AS (\n SELECT 'ALL'::text AS state,\n count(*) AS matchable_providers,\n count(*) FILTER (WHERE f.npi IS NULL) AS federally_invisible\n FROM overall_npi o\n LEFT JOIN fed_inforce f USING (npi)\n),\nu AS ( SELECT * FROM per_state UNION ALL SELECT * FROM overall )\nSELECT\n state,\n matchable_providers, -- NPI-identified denominator\n federally_invisible, -- NOT on the federal LEIE\n (matchable_providers - federally_invisible) AS on_federal_too, -- caught by both\n round(100.0 * federally_invisible / nullif(matchable_providers, 0), 1)\n AS pct_invisible\nFROM u\nORDER BY state;\n-- state matchable invisible on_federal_too pct_invisible\n-- ALL 4,851 3,117 1,734 64.3\n-- NY 2,254 1,347 907 59.8\n-- PA 974 569 405 58.4\n-- OH 673 363 310 53.9\n-- IA 313 263 50 84.0\n-- MD 263 221 42 84.0\n-- WA 210 178 32 84.8\n-- NC 149 128 21 85.9\n-- MS 138 106 32 76.8\n-- MT 41 15 26 36.6 (small sample — see study)\n-- GA 35 8 27 22.9 (small sample — see study)\n\n-- Rows with NO NPI — excluded from the matchable denominator above and reported\n-- separately. These in-force state exclusions cannot be matched to the federal\n-- list by identifier at all, so federal NPI-based screening cannot reach them.\nSELECT\n coalesce(state, 'ALL') AS state,\n count(*) FILTER (WHERE inforce) AS inforce_rows,\n count(*) FILTER (WHERE inforce AND npi IS NULL) AS inforce_no_npi_rows,\n count(DISTINCT npi) FILTER (WHERE inforce AND npi IS NOT NULL) AS inforce_distinct_npi\nFROM (\n SELECT state,\n nullif(btrim(npi), '') AS npi,\n (reinstatement_date IS NULL OR reinstatement_date > current_date) AS inforce\n FROM public.state_exclusions\n) se\nGROUP BY ROLLUP (state)\nORDER BY state NULLS LAST;\n-- state inforce_rows inforce_no_npi_rows inforce_distinct_npi\n-- NY 8,904 6,633 2,254\n-- PA 4,913 3,712 974\n-- OH 1,980 1,248 673\n-- MD 1,603 1,339 263\n-- GA 1,369 1,333 35\n-- IA 1,150 795 313\n-- WA 244 34 210\n-- MS 193 53 138\n-- MT 174 132 41\n-- NC 166 14 149\n-- ALL 20,696 15,293 4,851", "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)", "generated_by": "Fonteum — https://fonteum.com", "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included." }