{ "study": { "slug": "state-exclusion-federal-blind-spot-2026", "title": "Medicaid Exclusion List Blind Spots: State Bars the Feds Miss", "standfirst": "Of 4,949 providers with an active state Medicaid exclusion across the 13 state programs Fonteum ingests, 3,188 — 64.4% — have no record on the federal OIG LEIE. Adding the SAM.gov debarment list recovers only 191: 2,997 stay invisible to both federal lists. And 198 are barred across two or more states at once.", "desk": "financial-distress", "article_type": "Original Research", "published": "2026-06-19", "issue": 87, "doi": "", "url": "https://fonteum.com/research/state-exclusion-federal-blind-spot-2026", "methodology_version": "state-blind-spot/v1" }, "data_as_of": "2026-07-14", "datasets": [ { "slug": "oig-leie", "name": "OIG LEIE", "publisher": "HHS OIG — List of Excluded Individuals/Entities", "upstream_url": null } ], "key_findings": [ { "number": "3,188", "finding": "of 4,949 NPI-identified providers with an active state Medicaid exclusion (64.4%) carry no in-force record on the federal OIG LEIE — a federal-only screen clears them", "dataset": "state-exclusions" }, { "number": "2,997", "finding": "remain invisible to both federal lists — no OIG LEIE record and no SAM.gov debarment record; adding the second federal list recovers only 191 of the 3,188", "dataset": "sam-exclusions" }, { "number": "198", "finding": "NPIs are barred across two or more of the 13 states at once — one appears on seven state lists; 82 of the 198 still carry no federal LEIE record", "dataset": "state-exclusions" }, { "number": "74.2%", "finding": "of state exclusion rows carry no NPI at all — unmatchable to any federal list by identifier, reported separately and never matched by name", "dataset": "state-exclusions" } ], "faqs": [ { "q": "How many state-excluded providers does a federal check miss?", "a": "Across the 13 state Medicaid programs Fonteum currently ingests, 3,188 of 4,949 NPI-identified state-excluded providers — 64.4% — carry no in-force record on the federal OIG List of Excluded Individuals and Entities (LEIE). An organization that screens the federal LEIE alone returns nearly two in three state-barred providers as having no exclusion on file. The match is made on the National Provider Identifier only, never on a name." }, { "q": "Does adding the SAM.gov debarment list close the gap?", "a": "Barely. Layering the second federal list — the SAM.gov / GSA exclusion and debarment registry — on top of the OIG LEIE recovers only 191 of the 3,188. After both federal lists are checked, 2,997 NPI-identified state-excluded providers (60.6% of the 4,949) are still on neither. A second federal source closes roughly 6% of the federal-only blind spot, because both federal lists are downstream of, and lag, the state actions." }, { "q": "Why would a provider be excluded by a state but absent from the federal lists?", "a": "State Medicaid agencies run their own exclusion programs 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 a federal OIG exclusion or SAM.gov debarment ever following. The federal lists can adopt many state actions under permissive authority, but adoption is discretionary and lagged, so a large standing set of state bars never reaches the federal files at all." }, { "q": "How many providers are excluded in more than one state at once?", "a": "198 NPIs appear on two or more of the 13 state lists. The distribution is concentrated near the low end — 186 on two states, 11 on three — but one NPI sits on seven different states' exclusion lists. And 82 of the 198 multi-state providers carry no OIG LEIE record, so a federal-only screen clears a provider barred in multiple states as clean." }, { "q": "Which states are included, and why not all 50?", "a": "Thirteen state Medicaid programs publish a usable exclusion file and are ingested: New York (OMIG), Pennsylvania (DHS), Ohio (ODM), Iowa (Medicaid), Maryland (MDH), Washington (HCA), North Carolina (DHHS), Mississippi (DOM), New Hampshire (DHHS), North Dakota (HHS), Montana (DPHHS), Georgia (DCH-OIG), and Tennessee (TennCare). State Medicaid exclusion data is fragmented and inconsistently published, so coverage expands one primary source at a time. Every figure here describes the 13 ingested states, not the nation." }, { "q": "What about state exclusions with no NPI?", "a": "74.2% of state exclusion rows — 16,995 of 22,917 — carry no NPI at all. They cannot be matched to any federal list by identifier, so identifier-based screening cannot reach them. They are excluded from the matchable denominator and reported separately rather than guessed at by name. The headline figures describe the matchable, NPI-identified set." }, { "q": "Is a state exclusion the same as a federal one?", "a": "No. A state Medicaid exclusion and a federal OIG exclusion rest on different legal bases, are issued by different authorities, and bar different programs. Neither implies the other, and this study never treats one as a substitute for the other — it measures only whether the same NPI appears on each list. No conduct or wrongdoing is inferred; these are administrative exclusion-list facts, reported in aggregate." }, { "q": "Can I reproduce these numbers?", "a": "Yes. Every figure is a direct NPI join across the public state_exclusions, oig_leie_exclusions, and sam_exclusions tables. 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 LLC. (2026, June 19). Medicaid Exclusion List Blind Spots: State Bars the Feds Miss. Fonteum Research, Issue 87. https://doi.org/", "url": "https://fonteum.com/research/state-exclusion-federal-blind-spot-2026" }, "reproducible_sql": "-- Excluded by a state, invisible to a federal check — fully reproducible query.\n--\n-- Question: of the providers (by NPI) carrying an ACTIVE state Medicaid\n-- exclusion across the 13 state programs Fonteum currently ingests, how many\n-- are NOT present on the federal OIG LEIE — i.e. how many a federal-only\n-- screen would miss? And, layering the second federal list, how many are on\n-- neither the OIG LEIE nor the SAM.gov / GSA debarment registry? Plus the\n-- cross-state overlap: how many excluded NPIs appear on 2+ state lists.\n--\n-- This study extends the prior LEIE-only cut (federal-state-exclusion-gap-2026,\n-- 10 states) two ways: (1) it tests the FULL federal screening stack — OIG LEIE\n-- AND SAM.gov debarment — not a single list; (2) it adds the cross-state\n-- dimension. Coverage is now 13 states (NY OH GA PA NC MD WA IA MS MT NH ND TN).\n--\n-- Sources (all public, read-only):\n-- public.state_exclusions — State Exclusion Ring, 13 state Medicaid\n-- programs, 22,917 rows (5,922 carry an NPI;\n-- 16,995 — 74.2% — carry none). Data as of\n-- observed 2026-07-14.\n-- public.oig_leie_exclusions — OIG List of Excluded Individuals and\n-- Entities, federal monthly bulk download,\n-- release 2026-05-08, 68,055 active records\n-- (7,025 carry an NPI).\n-- public.sam_exclusions — SAM.gov / GSA federal exclusion & debarment\n-- registry, 323,930 active and unterminated\n-- rows (37,443 carry an NPI; 4,694 distinct\n-- NPIs) as observed 2026-07-14.\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 the no-NPI query).\n--\n-- \"In force\" mirrors the production exclusion lookup (src/lib/exclusions):\n-- state / LEIE : reinstatement_date IS NULL OR reinstatement_date > today\n-- SAM : termination_date IS NULL OR termination_date > today\n-- (isCurrentlyExcluded in src/lib/exclusions/types.ts). The OIG/state files drop\n-- reinstated parties, so the in-force set is \"any row by NPI\" net of future-dated\n-- reinstatements. Audit date basis: DATE '2026-07-14'.\n--\n-- Every headline figure in the study resolves to one of the rows below.\n\n-- ── HEADLINE: state-excluded NPIs invisible to a federal check ──────────────\n-- audit-claim: federal-blind-spot\nWITH state_inforce AS ( -- distinct in-force, NPI-identified state Medicaid exclusions\n SELECT DISTINCT nullif(btrim(npi), '') AS npi\n FROM public.state_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14')\n),\nleie_inforce AS ( -- distinct in-force, NPI-identified federal OIG exclusions\n SELECT DISTINCT nullif(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 > DATE '2026-07-14')\n),\nsam_inforce AS ( -- distinct in-force, NPI-identified SAM.gov / GSA debarments\n SELECT DISTINCT nullif(btrim(npi), '') AS npi\n FROM public.sam_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND status = 'Active'\n AND (termination_date IS NULL OR termination_date > DATE '2026-07-14')\n), counts AS (\n SELECT\n (SELECT count(*) FROM state_inforce) AS state_inforce_npi,\n (SELECT count(*) FROM state_inforce s\n LEFT JOIN leie_inforce l USING (npi) WHERE l.npi IS NULL) AS not_on_leie,\n (SELECT count(*) FROM state_inforce s\n JOIN leie_inforce l USING (npi)) AS also_on_leie,\n (SELECT count(*) FROM state_inforce s\n LEFT JOIN leie_inforce l USING (npi)\n LEFT JOIN sam_inforce sa USING (npi)\n WHERE l.npi IS NULL AND sa.npi IS NULL) AS not_on_leie_nor_sam,\n (SELECT count(*) FROM leie_inforce) AS leie_inforce_npi,\n (SELECT count(*) FROM sam_inforce) AS sam_inforce_npi\n)\nSELECT\n counts.*,\n round(100.0 * not_on_leie / state_inforce_npi, 1) AS not_on_leie_pct,\n not_on_leie - not_on_leie_nor_sam AS recovered_by_sam,\n round(100.0 * not_on_leie_nor_sam / state_inforce_npi, 1) AS not_on_both_pct,\n round(100.0 * not_on_leie / state_inforce_npi, 1)\n - round(100.0 * not_on_leie_nor_sam / state_inforce_npi, 1) AS recovered_percentage_points,\n round(\n 100.0 * (not_on_leie - not_on_leie_nor_sam) / not_on_leie,\n 1\n ) AS blind_spot_closed_pct\nFROM counts;\n-- state_inforce_npi not_on_leie also_on_leie not_on_leie_nor_sam leie_inforce_npi sam_inforce_npi\n-- 4,949 3,188 1,761 2,997 6,880 4,694\n-- => 3,188 / 4,949 = 64.4% of state-excluded NPIs carry NO in-force OIG LEIE record (federal-LEIE-only blind spot).\n-- => Adding the SAM.gov debarment list recovers only 3,188 - 2,997 = 191 of them; 2,997 (60.6%) remain\n-- invisible to BOTH federal lists. Difference 3.8 percentage points; 6.0% of the gap closed.\n\n-- ── Cross-state overlap: NPIs barred across 2+ of the 13 state lists ─────────\n-- audit-claim: cross-state-summary\nWITH npi_states AS (\n SELECT nullif(btrim(npi), '') AS npi, count(DISTINCT state) AS n_states\n FROM public.state_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14')\n GROUP BY 1\n)\nSELECT\n count(*) AS distinct_npi, -- 4,949\n count(*) FILTER (WHERE n_states >= 2) AS on_2plus_states, -- 198\n count(*) FILTER (WHERE n_states = 1) AS on_1_state, -- 4,751\n max(n_states) AS max_states -- 7\nFROM npi_states;\n\n-- Distribution of states-per-NPI (how many state lists a single NPI sits on):\n-- audit-claim: cross-state-distribution\nWITH npi_states AS (\n SELECT nullif(btrim(npi), '') AS npi, count(DISTINCT state) AS n_states\n FROM public.state_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14')\n GROUP BY 1\n)\nSELECT n_states, count(*) AS npis FROM npi_states GROUP BY n_states ORDER BY n_states;\n-- 1 state: 4,751 · 2 states: 186 · 3 states: 11 · 7 states: 1 (198 NPIs on 2+ states)\n\n-- Of the multi-state (2+) NPIs, how many are STILL invisible to the federal LEIE:\n-- audit-claim: multi-state-federal-gap\nWITH npi_states AS (\n SELECT nullif(btrim(npi), '') AS npi, count(DISTINCT state) AS n_states\n FROM public.state_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14')\n GROUP BY 1\n),\nleie_inforce AS (\n SELECT DISTINCT nullif(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 > DATE '2026-07-14')\n),\nmulti AS (SELECT npi FROM npi_states WHERE n_states >= 2)\nSELECT\n (SELECT count(*) FROM multi) AS multi_state_npi, -- 198\n (SELECT count(*) FROM multi m LEFT JOIN leie_inforce l USING (npi)\n WHERE l.npi IS NULL) AS multi_state_not_on_leie; -- 82\n-- 82 of the 198 providers barred in 2+ states carry no OIG LEIE record — barred coast-to-coast,\n-- yet a federal-only screen returns them clean.\n\n-- ── Per-state contribution (in-force distinct NPI, and how many not on LEIE) ─\n-- audit-claim: state-vector\nWITH state_inforce AS (\n SELECT DISTINCT state, nullif(btrim(npi), '') AS npi\n FROM public.state_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL\n AND (reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14')\n),\nleie_inforce AS (\n SELECT DISTINCT nullif(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 > DATE '2026-07-14')\n),\nflagged AS (\n SELECT s.state, s.npi, (l.npi IS NULL) AS not_on_leie\n FROM state_inforce s LEFT JOIN leie_inforce l USING (npi)\n)\nSELECT state,\n count(DISTINCT npi) AS excluded_npi,\n count(DISTINCT npi) FILTER (WHERE not_on_leie) AS not_on_leie\nFROM flagged GROUP BY state ORDER BY excluded_npi DESC;\n-- NY 2,259 (1,352 not on LEIE) · PA 973 (568) · OH 673 (363) · IA 313 (263) · MD 264 (222)\n-- · WA 210 (178) · NC 149 (128) · MS 138 (106) · NH 51 (37) · ND 47 (28) · MT 42 (16)\n-- · GA 35 (8) · TN 9 (8). Sum of per-state distinct NPI = 5,163 state-NPI pairs; distinct\n-- across states = 4,949 (the 198 multi-state NPIs are counted once per state here).\n\n-- ── Coverage + the unmatchable majority (rows with no NPI) ──────────────────\n-- audit-claim: raw-state-universe\nSELECT\n count(*) AS total_rows, -- 22,917\n count(*) FILTER (WHERE reinstatement_date IS NULL OR reinstatement_date > DATE '2026-07-14') AS inforce_rows, -- 21,003\n count(*) FILTER (WHERE nullif(btrim(npi), '') IS NOT NULL) AS rows_with_npi, -- 5,922\n count(*) FILTER (WHERE nullif(btrim(npi), '') IS NULL) AS rows_no_npi, -- 16,995\n round(100.0 * count(*) FILTER (WHERE nullif(btrim(npi), '') IS NULL) / count(*), 1) AS pct_no_npi, -- 74.2\n count(DISTINCT nullif(btrim(npi), '')) AS distinct_npi, -- 5,224 (incl. reinstated)\n count(DISTINCT state) AS states -- 13\nFROM public.state_exclusions;\n-- 74.2% of state exclusion rows carry no NPI at all. They cannot be matched to a federal\n-- list by identifier and are excluded from the matchable denominator, never name-matched.\n\n-- Full federal source universes, separate from the distinct-NPI join sets.\n-- audit-claim: federal-source-universes\nSELECT\n (SELECT count(*) FROM public.oig_leie_exclusions) AS leie_rows,\n (SELECT count(*) FROM public.oig_leie_exclusions\n WHERE nullif(btrim(npi), '') IS NOT NULL) AS leie_rows_with_npi,\n (SELECT count(*) FROM public.sam_exclusions\n WHERE status = 'Active'\n AND (termination_date IS NULL OR termination_date > DATE '2026-07-14')) AS sam_active_rows,\n (SELECT count(*) FROM public.sam_exclusions\n WHERE status = 'Active'\n AND (termination_date IS NULL OR termination_date > DATE '2026-07-14')\n AND nullif(btrim(npi), '') IS NOT NULL) AS sam_active_rows_with_npi,\n (SELECT count(DISTINCT btrim(npi)) FROM public.sam_exclusions\n WHERE status = 'Active'\n AND (termination_date IS NULL OR termination_date > DATE '2026-07-14')\n AND nullif(btrim(npi), '') IS NOT NULL) AS sam_active_distinct_npi;\n-- LEIE 68,055 rows / 7,025 with NPI\n-- SAM 323,930 active rows / 37,443 with NPI / 4,694 distinct NPI", "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." }