OIG Exclusionless than an hour ago
NPI: 1003000100
| LEIE row ID | 12345 |
| Type | PERMEXC |
| Exclusion date | 2024-01-15 |
| Description | Fraud |
| Dataset release | 2026-05-01 |
Source: OIG LEIE Exclusions List
Every provider record in the Fonteum graph is continuously evaluated against 5 deterministic rules: OIG exclusion status, anomalous payment patterns, specialty mismatches between NPPES and PECOS, enrollment lapses, and claim inactivity. Each signal cites the exact source row — not an ML confidence score, a primary-source fact.
Each of the 5 rules is a pure function of federal data rows. Rule a checks the OIG LEIE exclusion file. Rule b compares Open Payments totals against specialty-level percentiles. Rule c cross-joins NPPES and PECOS taxonomy columns. Rule d reads PECOS enrollment_status and MIPS recency. Rule e checks claim activity windows. No model, no threshold tuning.
Every signal carries a structured evidence JSON that cites the specific source row(s) that triggered it: LEIE row ID, Open Payments total, PECOS specialty, or enrollment status. You can independently verify any signal by looking up the cited record directly in the federal source.
Signals are recomputed nightly via an Inngest cron. Each recomputation is idempotent — the same source data always produces the same signal. If the source data changes (e.g. an exclusion is removed), the signal resolves automatically and resolved_at is set.
Most recent signals across the provider graph, ordered by severity then recency.
No active risk signals.
A provider NPI matched a record in the OIG LEIE monthly exclusion file. Excluded providers are barred from receiving payments from federal health programs. The signal cites the LEIE row ID, exclusion type, and exclusion date.
Source: OIG LEIE — oig.hhs.gov/exclusionsA provider's total CMS Open Payments amount for a given year exceeds the 95th percentile for their specialty. Elevated payment totals may indicate financial relationships with device or pharmaceutical manufacturers worth scrutiny in network contracting.
Source: CMS Open Payments — openpaymentsdata.cms.govThe primary taxonomy code in NPPES does not match the specialty registered in CMS PECOS. NPPES is self-reported; PECOS is validated at enrollment. A mismatch can indicate a stale NPPES record or an administrative discrepancy that may affect network directory accuracy.
Risk signals are available via the provider NPI API at /api/risk/[npi]. Each response carries full 14-tuple provenance linking the signal to its source row.
A provider's CMS PECOS enrollment status is inactive with no recent MIPS activity. An inactive enrollment status combined with no quality reporting activity may indicate the provider has left active Medicare participation, making inclusion in credentialing rosters inaccurate.
Source: CMS PECOS enrollment — data.cms.govA provider with an active NPI and enrollment status has no claims activity in the most recent 12-month window. This signal will activate once the claims dataset is integrated. It is currently a stub rule that will fire against CMS Part B claims data.
Source: CMS Part B Claims (pending integration)