Office of Inspector General
Department of Health and Human Services
Closing the Exclusions Referrals Gap
Comprised of a lawyer, IT security specialist, two auditors, and a facilities manager, Team Inspector General (IG) led an interdisciplinary and interagency effort leveraging existing IT resources and combining disparate agency data to identify and exclude healthcare providers convicted of opioid abuse, sexual assault, rape, and manslaughter from participating in Federal healthcare programs. This initiative yielded hundreds of measurable exclusion referrals that directly advanced the Department of Health and Human Services (HHS) Office of Inspector General (OIG) mission to protect taxpayer-funded healthcare programs (e.g., Medicare) and vulnerable beneficiaries from abuse. It also created a sustainable model that is already being replicated with other Federal law enforcement partners like the Federal Bureau of Investigation (FBI) and Department of Veterans Affairs (VA).
As background, OIG annually excludes about 3,500 individuals and entities from participating in Federal healthcare programs for certain misconduct, including criminal offenses related to controlled substances or patient abuse and neglect as well as Medicare and Medicaid fraud. Authorized under the Social Security Act, these exclusions are based largely on investigations by OIG, Medicaid Fraud Control Units, and state licensing boards. Other Federal, state, and local law enforcement partners are not required to refer convicted providers or other bad actors to OIG for exclusion, and OIG cannot exclude bad actors without knowing about them. In other words, this referral gap prevents OIG from excluding even more bad actors to better protect HHS programs and beneficiaries.
Team IG’s interdisciplinary, interagency initiative identified over 200 exclusion referrals by combining distinct data collected from two separate Federal agencies and other online sources for a new purpose -- to exclude bad actors from harming Federal healthcare programs and beneficiaries.
Focused on narrowing this referral gap by establishing a data-sharing relationship between Federal agencies, Team IG used information technology to identify potential exclusion referrals from online media reports of healthcare providers convicted by the Drug Enforcement Administration (DEA). Recognizing that DEA’s conviction data would allow OIG to exclude abusive opioid prescribers and thereby help both agencies fight the nation’s opioid epidemic, Team IG met with DEA officials and launched an interagency pilot project to identify convicted opioid prescribers in DEA’s internal data. The team referred those identified to OIG for exclusion while protecting PII data through secure file transfers. In addition, OIG provided certain exclusion data records to the DEA to revoke excluded providers’ licenses to prescribe opioids. Because this data-sharing pilot project successfully led to OIG exclusion and DEA revocation actions, DEA expanded the pilot to all 23 DEA regions nationwide and identified an additional 107 exclusion referrals for OIG. Team IG then drafted Standard Operating Procedures to document each agency’s role under an existing data-sharing agreement that is considered a model for similar relationships forming between OIG, FBI, and VA.
In addition to this DEA partnership, Team IG identified and tracked 125 other exclusion referrals generated internally with online search terms, leading to exclusion actions against individuals convicted of manslaughter, child abuse, and rape. Team IG also negotiated a successful trial period with a private vendor to evaluate whether the vendor’s sophisticated search tools and court document courier services allow OIG to streamline its workforce operations and exclude more bad actors, further protecting programs and beneficiaries.
In summary, Team IG’s interdisciplinary, interagency initiative identified over 200 exclusion referrals by combining distinct data collected from two separate Federal agencies and other online sources for a new purpose – to exclude bad actors from harming Federal healthcare programs and beneficiaries. These outstanding mission-driven results promote two HHS Priority Goals: (1) “Combined Data Analyses” by sharing interagency data to achieve results beyond the data’s primary purpose; and (2) “Reducing Opioid Morbidity and Mortality” by reducing opioid prescriptions from bad actors who are excluded from participating in Federal healthcare programs and lose their licenses to prescribe controlled substances. Team IG’s creative use of existing technology and data across agencies stands as a model of good government.