Exclusion Stats

Here’s a collection of five interesting stats related to the List of Excluded Individuals and Entities (LEIE). If healthcare compliance is something that affects your business, then these exclusion stats tell a cautionary tale.

1. The five most common causes for exclusions being handed out are as follows – license revocation or suspension; convictions for program-related crimes; convictions for patient abuse; felony charges for health care fraud; defaulting on health education loans. Of these, license revocation or suspension has accounted for nearly half the number of exclusions since 1977.
2. The top five states with maximum exclusions in 2015 were California (442), Florida (393), Texas (246), New York (173), and Ohio (159).  
3. Five states with the lowest number of exclusions in 2015 were District of Columbia (4), South Dakota (5), Delaware (9), Idaho (12), and Montana (13).
4. The number of individuals excluded from 2010 to 2015 has risen 45%. Exclusion numbers for the years are as follows – 2010 (2609), 2011 (2515), 2012 (3217), 2013 (3277), 2014 (3682), 2015 (3782).
5. Healthcare specialties that lead the list of exclusions are as follows – nurse / nurse’s aides, healthcare aides, general practitioners, chiropractic, pharmacists, and dentists.

License revocation, the most common cause for exclusion, is reported to the National Practitioner Data Bank (NPDB). Once an investigation is instituted, then even the voluntary surrender of the license by the individual will not save the person or business from being reported. Exclusion from federal health care programs is the usual fallout. The subject may also lose professional licenses in other states and jurisdictions. Removal from the provider panel of health insurers, debarment from government contracting and from contracting with entities that use Medicare are some of the other serious consequences that follow license revocation.

Program-related crimes, patient abuse or neglect, felony convictions arising from healthcare fraud, and felony convictions related to controlled substance attract a minimum exclusion period of five years. These are mandatory exclusion offenses. Two such offenses can lead to an exclusion of a minimum of ten years. Permanent exclusion results if convicted of three such mandatory exclusion offenses.

While felony convictions for health care fraud may only be fourth on the list in terms of numbers, they account for a huge chunk of the volume of losses. In 2015, Hexagram Home Health Care LLC of Illinois was charged for defrauding Medicare of at least 450,000 dollars. The scam revolved around this company bribing a third party referrer for sending elderly patients over for totally unnecessary treatment, which was paid for by Medicaid. Daniel Suarez of Miami, Florida, owner of eight pharmacies, skimmed off more than $20 million of the Medicare Part D program. He has been sentenced to nine years in prison.

Given that exclusions have steadily grown over the years, and frauds can take place at any level and in any segment of the healthcare industry, it becomes vitally important that your healthcare business executes the necessary pre-checks and exclusion screening before dealing with individuals or entities. Neglect can lead to hefty fines and even exclusions.