VA payer networks containing federally excluded providers (methodology demo)
Cross-references the AINPI federally-excluded cohort (LEIE or SAM, score >= 1.5) for Virginia against live FHIR provider directories of 4 publicly-queryable payer endpoints: Humana, Cigna, UnitedHealthcare (Optum FLEX, covers UHC commercial + UHC Community Plan + OptumRx), and Molina Complete Care (Azure APIM → Sapphire360). Two of the six VA Medicaid MCOs (UHC Community Plan, Molina) are now wired directly. The remaining four (Anthem HealthKeepers Plus, Aetna BH of VA, Sentara Community Plan, Virginia Premier) are Stage B fast-follow. Anchored in 42 CFR § 455.436 (federal database checks) and § 438.602 (Medicaid managed care directory oversight).
Headline
2 of 131 federally excluded VA-resident providers (LEIE or SAM, score >= 1.5) appear in at least one of 4 wired payer provider directories. Per-payer: Humana 0, Cigna 2, UnitedHealthcare 0, Molina 0.
2 / 131 = 1.53%
unit: count
What this means
Regulators
42 CFR § 438.602 requires MCO directory oversight. v1 finds matches in Cigna's public directory — a payer that aggregates commercial + Medicaid managed care lines in one FHIR endpoint. Each match is a § 455.436-relevant flag for state PI staff to investigate. The substantive VA-Medicaid version requires Stage B (Anthem HealthKeepers Plus, Aetna BH of VA, UHC Community Plan) which is not yet wired.
Payer data teams
Cigna is the v1 hit surface — if your organization carries any of the listed NPIs in your published provider directory, run an internal sweep against your provider data management workflow. Directory listing is operationally separate from active billing privileges, but the directory is the public-facing artifact regulators read first.
Provider data teams
If your NPI is matched here AND you believe the federal exclusion is in error, the LEIE search portal at exclusions.oig.hhs.gov and SAM.gov are the authoritative sources; pursue reinstatement with the excluding agency before contesting the directory listing.
Researchers
v1 reaches Humana (identifier search) and Cigna (name+filter). Neither is a primary VA Medicaid carrier; the actual VA Medicaid MCO products (Anthem HealthKeepers Plus, Aetna BH of VA, UHC Community Plan, Sentara, Molina, Virginia Premier) all require credentialed access. The Cigna name-search has a known false-negative class: cohort names are stored as "FAMILY, GIVEN" and may not exactly match payer-published names (typographic variants, hyphenated names, suffixes).
Null hypothesis
Zero federally-excluded VA-resident NPIs appear in any of the queried payer provider directories. Federal exclusion status and payer directory publication are in agreement.
Denominator
VA-resident NPIs in the AINPI high-risk cohort's critical bucket (composite score >= 1.5) flagged for OIG LEIE or SAM.gov active exclusion. Source: `high-risk-cohort-export.csv`, filtered to `state=VA AND bucket=critical AND (oig_excluded OR sam_excluded)`.
Data source
Live FHIR `Practitioner` queries against 4 publicly-queryable Da Vinci PDex Plan-Net endpoints. Humana, UHC, and Molina accept `?identifier=NPI` directly; Cigna does not (its CapabilityStatement returns `Search param not valid for resource: Practitioner by identifier` on 400) so we name-search via `?family=&given=` and post-filter the Bundle for the target NPI in `identifier[]`. UHC is reached via Optum FLEX (`https://flex.optum.com/fhirpublic/R4`) which serves UHC commercial + UHC Community Plan (Medicaid) + OptumRx in one tree of ~1,400 InsurancePlans. Molina is reached via the Azure APIM gateway at `https://api.interop.molinahealthcare.com/providerdirectory` (Sapphire360 backend, no auth required despite registration-gated dev portal). Anthem HealthKeepers Plus has a public endpoint at `cms_mandate/mcd/` but returns 500s; Aetna requires OAuth.
Notes
v1 methodology demonstration. Cross-references the VA-resident critical-bucket cohort (LEIE or SAM, score >= 1.5) against 4 publicly-queryable payer FHIR endpoints. Humana accepts `?identifier=NPI` directly; Cigna does not (its CapabilityStatement rejects identifier search) so we name-search and post-filter the Bundle by NPI. Each match is a data-quality and triage signal aligned with 42 CFR § 455.436 and § 438.602 — investigation, hearing rights, and reinstatement claims belong to the payer and the excluding agency. Provider directory listing alone does not establish current billing privileges or active patient assignment.