{
  "slug": "excluded-paid-by-medicaid",
  "title": "Federally excluded providers paid by Medicaid (HHS spending dataset)",
  "hypotheses": [
    "H29"
  ],
  "status": "published",
  "release_date": "2026-02-09",
  "generated_at": "2026-05-17T15:34:34+00:00",
  "methodology_version": "0.6.1-draft",
  "commit_sha": "334099e",
  "headline": "Of 6,840 currently-active federally-excluded NPIs across 52 state cohorts (per NPPES practice state), 1180 received Medicaid payments somewhere in T-MSIS 2018\u20132024 totalling $481,682,270 across 12,539,039 claim lines \u2014 but only 12 of those 1180 matches received payment STRICTLY AFTER the earliest of their LEIE / SAM exclusion-effective dates, totalling $3,249,457 in strict post-exclusion payments. The strict-filter result is the regulatorily significant signal \u2014 pre-exclusion billing reflects work the provider was legitimately authorized to do at the time, while post-exclusion billing is a direct 42 CFR \u00a7 455.436 audit-referral candidate. Source: HHS Medicaid Provider Spending dataset (2026-02-09 release). Two source-data limits: (1) the HHS file has no state-of-payment column, so paid amounts aggregate across every state Medicaid program that paid the NPI \u2014 state attribution is per NPPES practice state, not per state of payment; (2) NPPES deactivation is NOT used as an exclusion-effective date because it can be triggered by retirement / death / voluntary closure of practice.",
  "numerator": 12,
  "denominator": 6840,
  "numerator_full_window": 1180,
  "numerator_note": "Numerator = NPIs with payments STRICTLY AFTER their LEIE/SAM exclusion-effective date. Full-window numerator (any payment 2018-2024, regardless of pre/post exclusion) = 1180.",
  "denominator_note": "All-states scope = 6,840 unique federally-excluded NPIs across 52 state cohorts (active LEIE or SAM, score >= 1.5; state per NPPES practice state). Per-state CSVs at /api/v1/states/<state>/h29-excluded-paid.csv. Source-data limit: the HHS file does NOT carry a state-of-payment column, so per-NPI paid amounts aggregate across every state Medicaid program that paid the NPI. State attribution comes from NPPES practice state, not state of payment.",
  "data_source_release": "2026-02-09",
  "data_source_url": "https://opendata.hhs.gov/datasets/medicaid-provider-spending/",
  "chart": {
    "type": "bar",
    "unit": "count",
    "data": [
      {
        "label": "Cohort NPIs paid by Medicaid (full-window)",
        "value": 1180
      },
      {
        "label": "Strict post-exclusion subset",
        "value": 12
      }
    ]
  },
  "per_state": [
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      "state": "CA",
      "matches_full_window": 116,
      "matches_strict_post": 1,
      "paid_full_window": 64337137.94,
      "paid_strict_post": 20668.51
    },
    {
      "state": "OH",
      "matches_full_window": 114,
      "matches_strict_post": 1,
      "paid_full_window": 65740489.57,
      "paid_strict_post": 52524.64
    },
    {
      "state": "NY",
      "matches_full_window": 73,
      "matches_strict_post": 1,
      "paid_full_window": 45360017.58,
      "paid_strict_post": 194.0
    },
    {
      "state": "TX",
      "matches_full_window": 56,
      "matches_strict_post": 1,
      "paid_full_window": 5733379.16,
      "paid_strict_post": 234995.83
    },
    {
      "state": "FL",
      "matches_full_window": 53,
      "matches_strict_post": 0,
      "paid_full_window": 30916784.9,
      "paid_strict_post": 0.0
    },
    {
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      "matches_strict_post": 0,
      "paid_full_window": 13170785.77,
      "paid_strict_post": 0.0
    },
    {
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      "matches_strict_post": 0,
      "paid_full_window": 2727208.33,
      "paid_strict_post": 0.0
    },
    {
      "state": "KY",
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      "paid_full_window": 16394217.17,
      "paid_strict_post": 15595.65
    },
    {
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      "matches_strict_post": 0,
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      "paid_strict_post": 0.0
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    {
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  ],
  "notes": "All-states refresh. Per-state CSVs at /api/v1/states/<state>/h29-excluded-paid.csv carry one row per matched NPI with the directory-side context columns (top_hcpcs_codes, exclusion_source, billing-or-servicing axis, first/last paid month) needed to interpret the paid-amount headline. Source-file schema: 7 columns (billing/servicing NPI, HCPCS, claim month, patients, claim lines, paid amount), 238M rows, no state-of-payment column. State attribution comes from NPPES practice state, not the spending file. The HHS source aggregates fee-for-service, managed care, and CHIP; matches catch MCO-side exposures that AINPI's H26 4-payer sweep currently misses behind authentication walls. Disclosure timing: publish when available and high confidence (locked-in 2026-05-14 per roadmap \u00a710). DMAS receives 5-business-day review courtesy on VA-attributed rows before each refresh \u2014 operational courtesy, not a publication gate."
}