OIG finds $72 million in MA and Part D payments tied to excluded or felony-convicted providers
Oct 4, 2026 edition · GC-2026-0142 · Published 2026-10-04 · Version 2 · Announced
OIG identified $72 million in Medicare Advantage and Part D payments associated with 249 revoked NPIs absent from the Preclusion List. The brief describes timing, ownership and pharmacy-related gaps. It issues no specific recommendations and does not classify every payment as proven fraud.
What happened
An HHS OIG data brief issued September 28 and posted October 1 examines vulnerabilities in CMS’s provider-preclusion process. OIG reviewed 1,017 National Provider Identifiers associated with providers revoked from Medicare Parts A and B but absent from the Preclusion List during 2022 and 2023. It identified $72 million in Part C and Part D payments for services associated with 249 of those NPIs during 2022 through 2024. The Preclusion List concerns payments under Medicare Advantage and Part D; it is not simply another name for every Medicare enrollment or exclusion record.
OIG identifies delays and errors in adding or removing providers, organizations not listed when their owners were excluded or had specified felony convictions, and the regulatory treatment of pharmacies that fill prescriptions without prescribing. Those dispensing-only pharmacies were not subject to preclusion under the regulations described in the brief. The agency presents these as process vulnerabilities that may inform future regulations and guidance, and makes no specific recommendations to CMS. The figures do not establish that each associated claim was fraudulent or that CMS has ordered recovery of the entire amount. Operational follow-up must distinguish enrollment revocation, exclusion, preclusion and the facts of particular payments.
Scope and timing
- Authority status
- Announced
- Applicability
- Operationally relevant
- Audience
- Health systems, Provider networks
- Jurisdiction
- Federal
- Affected functions
- Provider Enrollment, Managed Care, Compliance, Revenue Cycle
- Responsible owner
- Provider Enrollment
Why it matters
A single screening list may miss material provider-status changes. MA, Part D, delegated networks and payment vendors need coordinated enrollment and exclusion controls.
Recommended action
Reconcile relevant provider status across enrollment, exclusion and preclusion sources. Investigate discrepancies, document the payment analysis and escalate repayment questions without treating the report as a blanket recoupment order.
Implementation playbook
- Reconcile relevant provider status across enrollment, exclusion and preclusion sources. Investigate discrepancies, document the payment analysis and escalate repayment questions without treating the report as a blanket recoupment order. Provider Enrollment · Due 2026-10-09
- Record the applicability assessment and validate the affected workflow with its operational owner. This is an internal review target, not an additional statutory deadline. Compliance · Due 2026-10-12
Sources
- MA organizations and prescription drug plans paid $72 million for services associated with excluded providers or certain felony convictionsOfficial · HHS OIG · 2026-10-01 · Source review 2026-10-04
Complete edition and supplemental material
This finding in the complete approved report →Regulatory horizons, CIA trends and implementation trackers remain in the full report.
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