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Office of Medicaid Inspector General (OMIG).

Validating Provider Eligibility

State Medicaid exclusions operate independently from federal OIG lists, creating compliance blind spots that can trigger devastating penalties for healthcare organizations. Each state's Office of Medicaid Inspector General maintains separate exclusion databases identifying providers banned from state Medicaid programs for fraud, abuse, and professional misconduct. CIChecked's OMIG screening protects your organization from state-specific exclusions that federal searches miss entirely while ensuring complete Medicaid program compliance.

What OMIG Screening Actually Reveals

  • State-Specific Medicaid Exclusions: Providers banned from individual state Medicaid programs independent of federal exclusions
  • State Program Violations: Medicaid fraud, patient abuse, and state healthcare violations that don't appear in federal databases
  • Provider Eligibility Verification: Current authorization status for state Medicaid program participation and billing (state-specific search protocols and verification requirements)
  • Multi-State Exclusion Intelligence: Complete coverage across all states where candidates have practiced or maintained licenses

State-Specific Verification Timeline: OMIG screening delivers results within 1-2 business days per state, providing rapid state Medicaid compliance verification for healthcare staffing and contracting decisions.

The State Medicaid Compliance Gap


Federal OIG exclusions don't capture state-specific Medicaid violations, creating dangerous compliance blind spots for healthcare organizations. Providers excluded from state Medicaid programs can participate in federal programs, while federal exclusions don't automatically trigger state program bans.

Each state maintains independent OMIG databases with different search procedures, verification requirements, and update frequencies. New York requires name and SSN verification, while other states use different identification protocols and search parameters requiring specialized expertise.

Complete Medicaid Program Prohibition


OMIG exclusions prohibit all activities related to state Medicaid programs including providing medical care, submitting claims, seeking payment, or participating in any capacity involving Medicaid beneficiaries. These restrictions extend beyond direct patient care to administrative and support functions.

Reading OMIG Exclusion Results: Current state Medicaid exclusions immediately disqualify providers from positions involving state Medicaid programs. Multi-state exclusions require comprehensive verification across all relevant jurisdictions where the organization operates or provides services.

Healthcare providers must verify OMIG status regularly, typically every 30 days, to maintain compliance with state Medicaid programs. Static screening at hire doesn't satisfy ongoing verification requirements for continuous program participation.

State Medicaid exclusion violations trigger substantial civil monetary penalties, program exclusions, and potential criminal charges for healthcare organizations employing excluded providers. These penalties can exceed federal sanctions in certain jurisdictions.

Bottom Line: OMIG screening protects healthcare organizations from state-specific Medicaid exclusions that federal searches miss entirely. Essential verification for complete Medicaid program compliance across all operational jurisdictions.

50 State Medicaid Exclusion Compliance Guide.


Medicaid exclusion verification requirements create a compliance minefield across all 50 states, with each jurisdiction maintaining separate state-level sanctions that federal OIG searches simply don't capture. Our comprehensive state-by-state intelligence exposes the enforcement complexities that trigger six-figure penalties - from monthly verification mandates to the seven states relying exclusively on federal reporting. Master the distinctions that separate compliance experts who investigate from vendors who just automate database checks.

The Alabama Attorney General's Office operates the state's Medicaid Fraud Control Unit through its Criminal Division, investigating allegations of fraud against Alabama Medicaid providers and patient abuse in Medicaid-funded facilities. The MFCU maintains its exclusion database through the Alabama Medicaid Agency, operating under federal oversight with $1.2 million in federal grants for FY2024. Healthcare employers must verify prospective employees against Alabama's separate state exclusion list, which includes providers banned for fraud, abuse, professional misconduct, or criminal convictions that federal OIG searches do not capture. Alabama requires mandatory verification of all healthcare providers against both federal and state exclusion databases before hiring, with ongoing monitoring throughout employment. Excluded individuals cannot receive reimbursement for providing Medicare and Medicaid services in any capacity, creating substantial compliance risks for employers who fail to conduct proper verification.
The Alaska Department of Health operates the state's Medicaid Program Integrity Unit in coordination with the Alaska Medicaid Fraud Control Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Alaska's challenging geographic terrain. Healthcare employers must verify prospective employees against Alaska's excluded provider list using name and identification verification, as the state maintains separate exclusion records for providers terminated from Alaska Medicaid programs that federal OIG searches do not capture. Alaska requires ongoing verification throughout employment, with excluded providers facing up to 10-year program bans for medical assistance fraud convictions and mandatory reinstatement applications requiring clear and convincing evidence of qualification. The state's exclusion categories include Medicaid fraud, patient abuse and neglect, professional misconduct, criminal convictions related to controlled substances, and violations of Alaska Statute 47.05.240. Alaska's remote geography and limited healthcare workforce create additional compliance risks where hiring mistakes are both financially devastating and operationally difficult to remedy due to extreme provider shortages.
The Arizona Health Care Cost Containment System (AHCCCS) operates its own Office of Inspector General to oversee the state's $22 billion Medicaid program in coordination with the Arizona Attorney General's Medicaid Fraud Control Unit. Healthcare employers must verify prospective employees against Arizona's state exclusion list using protocols outlined in Arizona Administrative Code R9-22-1802, as AHCCCS maintains separate exclusion records under A.R.S. § 36-2930.05 that federal OIG searches do not capture. Arizona requires ongoing verification throughout employment, with providers facing Credible Allegation of Fraud (CAF) payment suspensions that may be lifted pending investigation outcomes. Permanent exclusions are imposed for fraud, abuse, licensing violations, and criminal convictions, with non-automatic reinstatement requiring formal applications after exclusion periods expire. Arizona's recent enforcement actions include payment suspensions against over 100 behavioral health providers, demonstrating aggressive prosecution efforts in a state where provider networks are already strained. The state's exclusion verification requires specialized knowledge of Arizona's complex managed care structure involving multiple health plans, tribal healthcare relationships, and recent behavioral health oversight intensification.
The Arkansas Office of Medicaid Inspector General operates independently in coordination with the Arkansas Attorney General's Medicaid Fraud Control Unit to investigate Medicaid fraud and provider misconduct while consolidating fraud detection, prevention, and recovery into a single state agency. Healthcare employers must verify prospective employees against Arkansas's excluded provider list maintained by the Department of Human Services through the online portal, as Arkansas maintains separate state exclusion records that federal OIG searches do not capture. Arkansas requires ongoing verification throughout employment, with excluded providers prohibited from ordering, prescribing, or providing services to Medicaid clients and facing liability for all fees paid by Arkansas Medicaid for services rendered by excluded individuals. The state's exclusion categories include Medicaid fraud, patient abuse and neglect, false claims violations under the Arkansas Medicaid False Claims Act, and criminal convictions ranging from Class A misdemeanors ($2,500 fines, one year jail) to Class C felonies ($10,000 fines, 3-10 years prison). Arkansas has demonstrated aggressive enforcement with exclusion rates increasing from less than 2 per year (1989-1999) to nearly 10 per year (2000-2015).

The California Department of Health Care Services (DHCS) operates the state's Medicaid Program Integrity Division in coordination with the California Attorney General's Medicaid Fraud Control Unit to oversee the nation's largest Medicaid program serving over 15 million beneficiaries with a $132 billion annual budget. Healthcare employers must verify prospective employees against California's Suspended and Ineligible Provider List using protocols outlined in Welfare and Institutions Code sections 14043.6 and 14123, as DHCS maintains separate exclusion records for over 21,730 providers that federal OIG searches do not capture. California requires ongoing verification throughout employment, with automatic non-discretionary suspensions triggered for providers convicted of felonies, misdemeanors involving Medicaid fraud, federal exclusions, or healthcare license losses. The state's exclusion categories include Medicaid fraud, patient abuse and neglect, professional misconduct, criminal convictions related to controlled substances, and licensing violations. California's complex managed care structure involving 25 health plans, county-organized health systems, and recent CalAIM transformation creates additional compliance layers where verification mistakes can trigger devastating recoupment actions. The state has recovered $500 million in fraud recoveries, demonstrating aggressive enforcement.

The Colorado Department of Health Care Policy and Financing (HCPF) operates Health First Colorado (Medicaid), serving over 1.3 million beneficiaries in coordination with the Colorado Attorney General's Medicaid Fraud, Abuse & Neglect Unit (MFANU) across Colorado's complex managed care landscape involving multiple Regional Accountable Entities (RAEs). Healthcare employers must verify prospective employees against Colorado's "Terminations For Cause" exclusion list, as HCPF maintains separate exclusion records for providers terminated from Health First Colorado and Child Health Plan Plus programs that federal OIG searches do not capture. Colorado requires ongoing monthly verification against both state and federal databases, with HCPF authorized under recent HB24-1146 legislation to suspend provider enrollment for participation in organized fraud schemes when specific risk factors are documented. The state's exclusion categories include Medicaid fraud, patient abuse and neglect, professional misconduct, criminal convictions, licensing violations, and organized crime participation. Recent federal audit findings revealed Colorado failed to report $3.7 million in federal share overpayments from 70% of MFCU cases, demonstrating aggressive federal oversight that creates heightened compliance risks.

The Connecticut Office of the Chief State's Attorney operates the state's Medicaid Fraud Control Unit, established in 1978, working independently to investigate and prosecute fraud committed by healthcare professionals and facilities providing services paid by HUSKY Health (Connecticut's Medicaid program), serving over 950,000 beneficiaries. Healthcare employers must verify prospective employees against Connecticut's Administrative Actions List maintained by the Connecticut Department of Social Services, as the state maintains separate exclusion records for providers terminated from HUSKY Health programs that federal OIG searches do not capture. Connecticut requires ongoing verification throughout employment, with the MFCU investigating all providers who receive Medicaid funding regardless of whether victims are Medicaid recipients, as long as facilities receive Medicaid money. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in Medicaid-funded facilities, billing for unperformed services, double-billing, and professional misconduct. Recent federal inspection findings in 2021 confirmed that the Connecticut MFCU generally operated in accordance with applicable laws and performance standards across 121 case files reviewed. The MFCU employs professional criminal investigators, auditors, and prosecutors experienced in financial investigations, with recent enforcement actions including joint federal-state COVID-19 fraud task force operations and multiple False Claims Act settlements
The Delaware Department of Health and Social Services operates the state's Division of Medicaid & Medical Assistance (DMMA) Program Integrity Unit in coordination with the Delaware Attorney General's Medicaid Fraud Control Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Delaware's three-county jurisdiction, serving over 250,000 Medicaid beneficiaries. Healthcare employers must verify all possible employees against Delaware's excluded provider list maintained by DMMA through coordination with the Attorney General's enforcement actions, as Delaware maintains separate state exclusion records that federal OIG searches do not capture. Delaware requires ongoing verification throughout employment, with the MFCU receiving $1.94 million in federal funding for FY2021 and reporting 28 convictions, 47 civil judgments, and $5 million in combined recoveries from 2012-2014. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, and licensing violations under Delaware's bifurcated regulatory structure. Recent federal audit findings revealed Delaware's MFCU failed to report sentenced individuals to OIG within the required 30-day timeframes and missed National Practitioner Data Bank reporting requirements, demonstrating heightened federal oversight that creates additional compliance risks for healthcare employers who must navigate both criminal enforcement through the Attorney General and administrative oversight through DHSS-DMMA.
The District of Columbia Office of Inspector General operates its Medicaid Fraud Control Unit, certified by the U.S. Department of Health and Human Services on March 1, 2000, working in coordination with the Department of Health Care Finance's Division of Program Integrity to investigate Medicaid fraud and provider misconduct across the District's unique federal jurisdiction serving over 350,000 Medicaid beneficiaries with enhanced law enforcement authorities granted through the Inspector General Enhancement Amendment Act of 2022. Healthcare employers must verify prospective employees against DC's excluded provider list maintained by DHCF through coordination with the OIG's enforcement actions, as the District maintains separate exclusion records that federal OIG searches do not capture. DC requires ongoing verification throughout employment, with the MFCU receiving $4.21 million in combined federal and District funding for FY2024 ($3.16 million federal, $1.05 million District), demonstrating substantial enforcement capabilities for a jurisdiction of its size. The District's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, and licensing violations under DC's enhanced federal oversight structure. Recent federal inspection findings in 2022 identified challenges with limited law enforcement authority that have since been remedied through legislative amendments, while noting strong working relationships with federal partners, including HHS-OIG, FBI, and U.S. Attorney's Office, creating heightened compliance expectations for healthcare employers operating in the nation's capital, where federal and District enforcement intersect.
The Florida Agency for Health Care Administration operates its Office of Medicaid Program Integrity within the Division of Health Quality Assurance, working in coordination with the Florida Attorney General's Medicaid Fraud Control Unit to investigate Medicaid fraud and provider misconduct across the nation's fourth-largest Medicaid program serving over 4 million beneficiaries through the complex Statewide Medicaid Managed Care (SMMC) 3.0 program implemented across nine regional networks in February 2025. Healthcare employers must verify prospective employees against Florida's AHCA Sanctioned Provider database maintained through coordination with the MFCU's enforcement actions, as Florida maintains separate state exclusion records that federal OIG searches do not capture. Florida requires ongoing monthly verification throughout employment, with the MFCU receiving $27.73 million in combined federal and state funding for FY2022 ($20.8 million federal, $6.93 million state) and obtaining over $70 million in settlements and judgments from 2019-2024, demonstrating aggressive enforcement in a state with 9,254 providers historically listed on federal exclusion databases since 1978. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, and licensing violations under Florida Statute Chapter 409.913. Florida's managed care complexity involving multiple health plans across restructured regional networks, combined with the Care Provider Background Screening Clearinghouse requirements established under House Bill 943, creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions across one of the nation's most aggressively monitored Medicaid programs.
The Georgia Department of Law operates the state's Medicaid Fraud and Patient Protection Division in coordination with the Georgia Department of Community Health's Office of Inspector General, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Georgia's 10+ million residents served through the state's complex managed care landscape involving multiple CMOs and health plans. Healthcare employers must verify prospective employees against Georgia's OIG Exclusions List maintained by the Department of Community Health through coordination with the Attorney General's enforcement actions, as Georgia maintains separate state exclusion records that federal OIG searches do not capture. Georgia requires ongoing monthly verification throughout employment using the Georgia Criminal History Check System (GCHEXS) with fingerprint-based background checks, with the Medicaid Fraud Division receiving federal funding and obtaining over $190 million in recoveries since 2011 ($29.4 million in FY2013 alone), demonstrating aggressive enforcement across a state serving over 2.8 million Medicaid beneficiaries. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, and licensing violations under Georgia's Healthcare Facility Regulation structure. Georgia's managed care complexity involving multiple health plans and the GCHEXS mandatory fingerprint verification system, combined with explicit requirements that providers "immediately report" any discovered exclusions among employees or contractors, creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions across one of the Southeast's most aggressively monitored Medicaid programs.
The Hawaii Department of Human Services operates the Med-QUEST Division's Program Integrity Unit in coordination with the Hawaii Attorney General's Medicaid Fraud Control Unit to investigate Medicaid fraud and provider misconduct across Hawaii's unique island geography, serving over 350,000 Medicaid beneficiaries through the QUEST Integration managed care program. Healthcare employers must verify prospective employees against Hawaii's excluded provider list maintained by the Med-QUEST Division through monthly searches as required by federal regulations, as Hawaii maintains separate state exclusion records that federal OIG searches do not capture. Hawaii requires ongoing verification throughout employment, with the MFCU receiving federal funding and working with the National Association of Medicaid Fraud Control Units to investigate complex fraud schemes, including recent settlements like the $101,416 restitution recovered from Precision Diagnostics for false Medicaid claims involving unnecessary urine drug testing. The state's exclusion categories include Medicaid fraud, patient abuse and neglect, professional misconduct, criminal convictions related to controlled substances, and licensing violations under Hawaii's managed care structure involving five health plans: AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan, and UnitedHealthcare Community Plan. Hawaii's challenging island geography creates heightened compliance risks where provider verification mistakes can trigger devastating operational disruptions across already strained healthcare networks, with federal oversight noting historically low case outcomes that required enhanced enforcement coordination between state agencies and federal partners to strengthen fraud detection capabilities.
The Idaho Office of the Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Idaho Department of Health and Welfare's Medicaid Program Integrity Unit to investigate Medicaid fraud and provider misconduct across Idaho's challenging geographic terrain, serving over 400,000 Medicaid beneficiaries through four managed care programs: Standard, Basic, Enhanced, and Medicare Medicaid Coordinated plans. Healthcare employers must verify prospective employees against Idaho's Medicaid Exclusion List maintained through coordination between the Attorney General's enforcement actions and the Department of Health and Welfare's program integrity oversight, as Idaho maintains separate state exclusion records that federal OIG searches do not capture. Idaho requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and achieving 13 indictments, 11 convictions, 28 civil settlements and judgments, and nearly $5.3 million in recoveries during FYs 2015-2017 despite operational challenges noted in federal oversight reviews. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in Medicaid-funded facilities, professional misconduct, billing for services not performed, double-billing, and criminal convictions related to healthcare fraud under Idaho's bifurcated enforcement structure. Idaho's rural geography and limited healthcare workforce create additional compliance risks where hiring mistakes can trigger $10,000 civil penalties per claim for services associated with excluded individuals, with recent enforcement actions demonstrating aggressive prosecution across multiple counties, including Ada, Twin Falls, Bannock, Canyon, and Shoshone counties for provider fraud involving false documentation and billing irregularities.
The Illinois State Police operates the state's Medicaid Fraud Control Unit in the unique organizational structure of being housed within law enforcement rather than the Attorney General's office, working in coordination with the Illinois Department of Healthcare and Family Services Office of Inspector General to investigate Medicaid fraud and provider misconduct across the nation's fifth-largest Medicaid program serving over 2.7 million beneficiaries through multiple managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Illinois's Provider Sanctions List maintained by the HFS Office of Inspector General and through the searchable sanctions database, as Illinois maintains over 2,978 active exclusions and separate state sanction records that federal OIG searches do not capture. Illinois requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and operating from multiple locations including Tinley Park, while the Attorney General maintains additional MFCU operations in Belleville, Chicago, Montvale, Oak Brook, and Rockford to ensure statewide coverage. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions, billing for services not performed, and sanctions under 305 Ill. Comp. Stat. 5/12-4.25 with penalties including treble damages and fines of up to $10,000 per claim for services billed while employing sanctioned providers. Illinois's complex dual-oversight structure involving both State Police and Attorney General operations creates unique compliance challenges noted in federal oversight reviews, with the state's Enhanced Eligibility Verification Project and $150 million information system modernization demonstrating aggressive program integrity enforcement across one of the nation's most closely monitored Medicaid programs.
The Indiana Family and Social Services Administration operates its Office of Medicaid Policy and Planning Program Integrity Unit in coordination with the Indiana Attorney General's Medicaid Fraud Control Unit (MFCU), which was federally certified on June 24, 1982, to investigate Medicaid fraud and provider misconduct across Indiana's $12.4 billion annual Medicaid program serving over 1.8 million beneficiaries through multiple managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Indiana's Terminated Provider List maintained by FSSA through federal regulations requiring states to provide notice when provider enrollment has been terminated "for cause," as Indiana maintains separate state exclusion records that federal OIG searches do not capture. Indiana requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and achieving over $110 million in combined civil and criminal recoveries from FYs 2010-2012, demonstrating aggressive enforcement capabilities. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, adverse licensure actions, federal exclusions, fraudulent conduct, abuse of billing privileges, misuse of billing numbers, falsified enrollment information, and falsified medical records under Indiana's dual-oversight structure. Indiana's complex managed care landscape and the MFCU's statewide investigative authority create heightened compliance risks where verification mistakes can trigger substantial penalties, with excluded providers prohibited from receiving reimbursement for providing Medicare and Medicaid services in any capacity across one of the Midwest's most closely monitored Medicaid programs.
The Iowa Department of Health and Human Services operates its Program Integrity Unit in coordination with the Iowa Attorney General's Office Medicaid Fraud Control Unit, working to investigate Medicaid fraud and provider misconduct across Iowa's Medicaid program, serving over 680,000 beneficiaries through managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Iowa's Medicaid Sanction List maintained by the HHS Program Integrity Unit through verification requests, as Iowa maintains separate state exclusion records that federal OIG searches do not capture. Iowa requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and achieving positive case outcomes despite staffing challenges noted in federal oversight reviews, demonstrating effective enforcement capabilities. The state's exclusion categories include involuntary termination from participation, involuntary suspension from participation, OIG exclusions, Medicare revocations, outstanding overpayments, and sanctions for violations of Iowa Medicaid Program requirements under Iowa Administrative Code 441. Iowa's dual-oversight structure involving both HHS Program Integrity and the Attorney General's MFCU creates heightened compliance risks where verification mistakes can trigger mandatory suspension from participation with outstanding overpayments, automatically resulting in program suspension, with providers required to maintain correct addresses for correspondence or face sanctions that can include suspension of payments and participation with the Medicaid Program.
The Kansas Department of Health and Environment operates its Division of Health Care Finance Program Integrity Unit in coordination with the Kansas Attorney General's Office Medicaid Fraud Control Unit and the Office of the Medicaid Inspector General (OMIG), creating a tri-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Kansas's KanCare Medicaid program serving over 415,000 beneficiaries through three managed care organizations. Healthcare employers must verify prospective employees against Kansas's Terminated Provider List maintained by the KDHE Division of Health Care Finance, as Kansas maintains separate state exclusion records that federal OIG searches do not capture. Kansas requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and achieving nearly $66 million in combined civil and criminal recoveries and 44 convictions from FYs 2009-2011, demonstrating aggressive enforcement capabilities despite federal oversight findings regarding internal control weaknesses and reporting compliance. The state's exclusion categories include provider agreement terminations for reasons specified under KAR 30-5-60, Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions, and violations of the Kansas Medicaid Fraud Control Act under K.S.A. 21-5925 through 21-5934. Kansas's complex tri-agency oversight structure involving KDHE's Division of Health Care Finance, the Attorney General's MFCU, and the independent Office of the Medicaid Inspector General creates heightened compliance risks where verification mistakes can trigger termination from participation, with excluded providers prohibited from receiving reimbursement for Medicaid services in any capacity across one of the nation's most closely monitored managed care programs.
The Kentucky Attorney General operates the Office of Medicaid Fraud and Abuse Control (OMFAC) within the Medicaid Fraud Control Unit, working in coordination with the Kentucky Cabinet for Health and Family Services to investigate Medicaid fraud and provider misconduct across Kentucky's Medical Assistance Program, serving vulnerable populations through multiple managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Kentucky's excluded provider list maintained by the Attorney General's Office through coordination with federal oversight agencies, as Kentucky maintains separate state exclusion records that federal OIG searches do not capture. Kentucky requires ongoing verification throughout employment, with the MFCU receiving federal grant funding and achieving significant enforcement outcomes including convictions for nearly $8,000 in Medicaid fraud and participation in multi-million dollar national healthcare fraud takedowns involving laboratory fraud schemes exceeding $7.2 million and sober home operations billing $26.7 million in fraudulent claims. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for medically unnecessary services, violations of the Controlled Substances Act, and Anti-Kickback Statute violations under Kentucky's aggressive enforcement structure. Kentucky's comprehensive enforcement approach involving joint operations with federal agencies, including HHS-OIG, FBI, DEA, and other law enforcement partners, creates heightened compliance risks where verification mistakes can trigger significant civil penalties, exclusions from federal healthcare programs, and criminal prosecution across one of the nation's most aggressively monitored state Medicaid fraud control operations.
The Louisiana Attorney General operates the state's Medicaid Fraud Control Unit (MFCU), recognized three times as the number one MFCU in the nation by the U.S. Department of Health and Human Services Office of Inspector General, working in coordination with the Louisiana Department of Health's Program Integrity Unit to investigate Medicaid fraud and provider misconduct across Louisiana's $13+ billion Medicaid program serving over 1.6 million beneficiaries through managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Louisiana's State Adverse Actions List maintained by the Louisiana Department of Health through the online database search system, as Louisiana maintains separate state exclusion records that federal OIG searches do not capture. Louisiana requires ongoing verification throughout employment with mandatory monthly checks, and employers must notify LDH within ten working days of discovering any exclusions among current employees, with the MFCU receiving federal grant funding and achieving hundreds of convictions and millions in recoveries since 1978, including recent enforcement actions resulting in 20 arrests for personal care attendant fraud and multiple provider agreement terminations. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, for-cause terminations, and billing violations under Louisiana Revised Statutes 46:437 et seq. and Louisiana R.S. 14:126.3.1, with employment of excluded individuals constituting a criminal violation. Louisiana's aggressive enforcement structure involving joint federal-state operations and comprehensive qui tam lawsuit provisions under 1997 legislation creates heightened compliance risks where verification mistakes can trigger significant civil penalties, criminal prosecution, and provider agreement terminations across one of the nation's most closely monitored and successful Medicaid fraud control programs.
The Maine Office of the Attorney General operates the Healthcare Crimes Unit, the state's federally designated Medicaid Fraud Control Unit certified by the U.S. Department of Health and Human Services, working in coordination with the Maine Department of Health and Human Services Office of MaineCare Services to investigate Medicaid fraud and provider misconduct across Maine's MaineCare program serving over 350,000 beneficiaries with $3.5+ billion in annual expenditures. Healthcare employers must verify prospective employees against Maine's Excluded Providers Database maintained by DHHS through the Health PAS Online Portal search function, as Maine maintains separate state exclusion records that federal OIG searches do not capture. Maine requires ongoing verification throughout employment with mandatory monthly checks through the Provider Exclusion Check system, with the Healthcare Crimes Unit receiving $1,461,428 in federal funding (75%) and $487,140 in state funding (25%) for FY2025, demonstrating substantial enforcement capabilities for a state of its size. The state's exclusion categories include MaineCare fraud, patient abuse and neglect in healthcare facilities receiving MaineCare funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, and violations of Maine's healthcare fraud statutes. Maine's rural geography and limited healthcare workforce create additional compliance risks where verification mistakes can trigger devastating recoupment actions and civil penalties, with excluded providers prohibited from receiving reimbursement for MaineCare services in any capacity across one of New England's most closely monitored Medicaid programs with aggressive enforcement.
The Maryland Office of the Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Maryland Department of Health Office of Inspector General Program Integrity Division to investigate Medicaid fraud and provider misconduct across Maryland's Medical Assistance Program, serving over 1.3 million beneficiaries with $15+ billion in annual expenditures. Healthcare employers must verify prospective employees against Maryland's MMA Providers and Other Entities Sanctioned List maintained by the Maryland Department of Health through the sanctioned providers database, as Maryland maintains separate state exclusion records that federal OIG searches do not capture. Maryland requires ongoing verification throughout employment with mandatory checks against both state and federal databases, with the Medicaid Fraud Control Unit receiving federal grant funding and achieving significant enforcement outcomes, demonstrating aggressive enforcement capabilities across one of the mid-Atlantic's most closely monitored Medicaid programs. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, prescription drug fraud through pill mill operations, and violations of Maryland's healthcare fraud statutes under Criminal Law Article § 8-515. Maryland's complex managed care structure involving HealthChoice and fee-for-service arrangements, combined with enhanced enforcement through joint federal-state task forces targeting controlled substance diversion and fraudulent billing schemes, creates heightened compliance risks where verification mistakes can trigger felony charges punishable by up to five years incarceration and $100,000 fines, with excluded providers prohibited from receiving reimbursement for Maryland Medicaid services in any capacity across one of the nation's most aggressively prosecuted healthcare fraud jurisdictions.
The Massachusetts Office of the Attorney General operates the state's Medicaid Fraud Division, the federally certified Medicaid Fraud Control Unit annually recertified by the U.S. Department of Health and Human Services, working in coordination with MassHealth (Massachusetts' Medicaid program) to investigate Medicaid fraud and provider misconduct across the nation's third-largest Medicaid program serving over 2.1 million beneficiaries with $18+ billion in annual expenditures. Healthcare employers must verify prospective employees against Massachusetts' Suspended or Excluded MassHealth Providers List maintained by MassHealth and updated monthly, as Massachusetts maintains separate state exclusion records that federal OIG searches do not capture. Massachusetts requires ongoing monthly verification throughout employment with mandatory checks against both state and federal databases, with providers required to immediately report any discovered exclusions to the Executive Office of Health and Human Services Compliance Office. The state's exclusion categories include MassHealth fraud, patient abuse and neglect in long-term care facilities and healthcare settings, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, Anti-Kickback Statute violations, and violations of the Massachusetts False Claims Act. Massachusetts' complex healthcare landscape involving sophisticated academic medical centers, extensive managed care networks, and aggressive enforcement through joint federal-state task forces creates heightened compliance risks where verification mistakes can trigger devastating multimillion-dollar settlements, with excluded providers prohibited from receiving reimbursement for MassHealth services in any capacity across one of the nation's most aggressively prosecuted and highest-recovery Medicaid fraud jurisdictions.
The Michigan Office of Health Services Inspector General operates within the Michigan Department of Health and Human Services in coordination with the Michigan Attorney General's Medicaid Fraud Control Unit to investigate Medicaid fraud and provider misconduct across Michigan's $15+ billion Medicaid program serving over 2.8 million beneficiaries through multiple managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Michigan's Sanctioned Provider List maintained by MDHHS through the online database search system available in both Excel and PDF formats, as Michigan maintains separate state exclusion records that federal OIG searches do not capture. Michigan requires ongoing verification throughout employment with mandatory checks against both state and federal databases, with the MFCU receiving federal grant funding but facing federal oversight challenges regarding low fraud referral rates from the state Medicaid agency, fiscal control weaknesses, and staffing levels that haven't scaled with growing Medicaid expenditures despite serving nearly 3 million beneficiaries. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, and licensing violations under Michigan's dual-oversight structure involving both OHSIG administrative enforcement and Attorney General criminal prosecution. Michigan's complex managed care landscape and the state's Clean Slate legislation that automatically clears certain criminal records after specified timeframes create additional compliance risks where verification mistakes can trigger significant civil penalties and recoupment actions, with excluded providers prohibited from receiving reimbursement for Michigan Medicaid services in any capacity across one of the Great Lakes region's most closely monitored but understaffed Medicaid fraud control programs.
The Minnesota Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Minnesota Department of Human Services Program Integrity and Oversight Division to investigate Medicaid fraud and provider misconduct across Minnesota Health Care Programs (MHCP), serving over 1.4 million beneficiaries through multiple managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Minnesota's Excluded Provider Lists maintained by DHS through separate individual and group provider databases updated monthly, as Minnesota maintains separate state exclusion records that federal OIG searches do not capture. Minnesota requires ongoing monthly verification throughout employment against both state and federal databases. The state's exclusion categories include Medicaid fraud, theft, abuse, error, noncompliance in connection with Minnesota health care programs, patient abuse and neglect in healthcare facilities, and professional misconduct under Minnesota's dual-oversight structure. Minnesota's recent $18.5 million NUWAY Alliance settlement and aggressive prosecution of multi-million dollar fraud schemes like the PITSTOP66 investigation demonstrate sophisticated enforcement capabilities, but the state faces challenges with the MFCU director serving as the sole supervisor and receiving few patient abuse referrals from other state agencies, creating heightened compliance risks where verification mistakes can trigger automatic claim denials and fund recovery actions across one of the nation's most successful but understaffed Medicaid fraud control programs.
The Mississippi Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Mississippi Division of Medicaid's Program Integrity Office to investigate Medicaid fraud and provider misconduct across Mississippi's $6 billion Medicaid program serving approximately 754,585 beneficiaries through managed care organizations, including three MississippiCAN plans (Humana, Molina, and UnitedHealthcare) and fee-for-service arrangements. Healthcare employers must verify prospective employees against Mississippi's Provider Terminations List maintained by the Division of Medicaid, as Mississippi maintains separate state exclusion records for providers terminated from participation that federal OIG searches do not capture. Mississippi requires ongoing monthly verification throughout employment against both state and federal databases, with the Division of Medicaid recovering $8.6 million in FY 2017 through various program integrity audits despite facing significant federal oversight challenges. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions, billing for services not performed, and violations under Miss. Code Ann. §43-13-121 and 42 CFR §455.416. Mississippi's recent federal audit findings reveal severe compliance deficiencies where the state failed to report and return $4.5 million in MFCU-determined overpayments ($3.7 million federal share), stopped working joint cases with federal partners in 2018, maintained limited communication with federal oversight agencies, and received few fraud referrals from the Medicaid agency, creating heightened compliance risks where verification mistakes can trigger automatic claim rejections and aggressive recoupment actions across one of the nation's most federally scrutinized but operationally challenged Medicaid fraud control programs.
The Missouri Office of the Attorney General operates the state's Medicaid Fraud Control Unit, certified by the U.S. Department of Health and Human Services and nationally recognized in 2024 with the Inspector General's Award for Excellence in Fighting Fraud, Waste and Abuse, working in coordination with the Missouri Medicaid Audit and Compliance (MMAC) to investigate Medicaid fraud and provider misconduct across Missouri's $13+ billion Medicaid program serving over 1 million beneficiaries through managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against Missouri's excluded provider list maintained by MMAC through coordination with the Attorney General's enforcement actions, as Missouri maintains separate state exclusion records that federal OIG searches do not capture. Missouri requires ongoing verification throughout employment, demonstrating aggressive enforcement capabilities that resulted in national recognition as a model organization. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, unbundling, double billing, kickbacks, and violations under Missouri's False Claims Act, with penalties including treble damages and exclusions from all government healthcare programs. Missouri's recent high-profile enforcement actions include multi-million dollar civil settlements, joint federal-state prosecutions, and systematic targeting of personal care fraud schemes, creating heightened compliance risks where verification mistakes can trigger automatic claim denials and aggressive recoupment actions across one of the nation's most successful and federally recognized Medicaid fraud control programs.
The Montana Department of Justice operates the state's Medicaid Fraud Control Unit within the Division of Criminal Investigation in coordination with the Montana Department of Public Health and Human Services Office of Inspector General Program Compliance Bureau, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Montana's $1.4 billion Medicaid program serving over 350,000 beneficiaries through Montana Healthcare Programs and the Passport primary care case management system. Healthcare employers must verify prospective employees against Montana's Excluded or Terminated Montana Medicaid Providers List maintained by DPHHS through the online database updated regularly with over 150 active exclusions, as Montana maintains separate state exclusion records under Administrative Rules of Montana (ARM) 37.85.507 that federal OIG searches do not capture. Montana requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Montana Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, and violations under Montana's healthcare fraud statutes, with both OIG exclusions and state terminations tracked separately. Montana's rural geography, spanning 147,000 square miles and a limited healthcare workforce, creates additional compliance risks where verification mistakes can trigger devastating operational disruptions across already strained provider networks, with excluded providers prohibited from receiving reimbursement for Montana Healthcare Programs services in any capacity across one of the nation's most geographically challenging but effectively monitored rural Medicaid programs.
The Nebraska Office of the Attorney General operates the state's Medicaid Fraud and Patient Abuse Unit in coordination with the Nebraska Department of Health and Human Services Division of Medicaid & Long-Term Care Program Integrity Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Nebraska's $2 billion Medicaid program serving over 265,000 beneficiaries through the Heritage Health managed care system. Healthcare employers must verify prospective employees against Nebraska's Sanctioned Provider List maintained by the DHHS Program Integrity Unit, as Nebraska maintains separate state exclusion records that federal OIG searches do not capture. Nebraska requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Nebraska Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double billing, upcoding, billing for unnecessary services, and violations under Nebraska's False Medicaid Claims Act with Class IV felony penalties. Nebraska's complex Heritage Health managed care transformation launched in 2023 involving integrated physical health, behavioral health, pharmacy, and dental services across $1.2 billion in annual expenditures creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions and civil penalties, with excluded providers prohibited from receiving reimbursement for Nebraska Medicaid services in any capacity across one of the nation's most recently restructured and closely monitored managed care programs operating under enhanced federal oversight.
The Nevada Office of the Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Nevada Division of Health Care Financing and Policy (DHCFP) Program Integrity Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across Nevada's $4+ billion Medicaid program serving over 788,000 beneficiaries. Healthcare employers must verify prospective employees against Nevada's Provider Exclusions List maintained by DHCFP and updated periodically with separate tracking of Nevada Medicaid sanctions versus federal OIG exclusions, as Nevada maintains state exclusion records that federal OIG searches do not capture. Nevada requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Nevada Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, kickback schemes, and violations under Nevada's healthcare fraud statutes with recent major enforcement actions including $94 million allograft fraud schemes and behavioral health company prosecutions involving restitution in the millions. Nevada's complex managed care landscape involving four competing MCOs across urban Clark and Washoe counties with planned 2026 statewide expansion into rural areas serving an additional 75,000 residents creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions and civil penalties, with excluded providers prohibited from receiving reimbursement for Nevada Medicaid services in any capacity across one of the nation's fastest-growing and most closely monitored managed care programs.
The New Hampshire Office of the Attorney General operates the state's Medicaid Fraud Control Unit, federally certified by the U.S. Department of Health and Human Services, working in coordination with the New Hampshire Department of Health and Human Services Program Integrity Unit to investigate Medicaid fraud and provider misconduct across New Hampshire's Medicaid program serving over 130,000 beneficiaries through 22,000+ enrolled providers across 86 licensed healthcare facilities. Healthcare employers must verify prospective employees against New Hampshire's Excluded Provider List maintained by DHHS through coordination with the Attorney General's enforcement actions, as New Hampshire maintains separate state exclusion records that federal OIG searches do not capture. New Hampshire requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include New Hampshire Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, double billing, kickback schemes, and violations under New Hampshire's healthcare fraud statutes with Class A felony penalties up to 15 years imprisonment and $4,000 fines. New Hampshire's rural geography serving 7,000+ healthcare facility residents across challenging terrain creates additional compliance risks where verification mistakes can trigger devastating recoupment actions and civil penalties, with excluded providers prohibited from receiving reimbursement for New Hampshire Medicaid services in any capacity across one of New England's most actively prosecuted Medicaid fraud jurisdictions, despite federal oversight challenges noted in 2017 regarding low case outcomes and referral rates that have since been addressed through enhanced enforcement coordination.
The New Jersey Office of the Insurance Fraud Prosecutor operates the state's Medicaid Fraud Control Unit within a unique organizational structure, working in coordination with the New Jersey Department of Human Services Division of Medical Assistance and Health Services to investigate Medicaid fraud and provider misconduct across New Jersey's $18+ billion NJ FamilyCare Medicaid program serving over 1.8 million beneficiaries. Healthcare employers must verify prospective employees against New Jersey's Ineligible Provider List maintained by the Division of Revenue and Enterprise Services through the online debarment search system, as New Jersey maintains separate state exclusion records for providers terminated, suspended, disqualified, or debarred from participation that federal OIG searches do not capture. New Jersey requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include NJ FamilyCare fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, double billing, kickback schemes, and violations under New Jersey's Health Care Claims Fraud Act with Class A felony penalties up to 15 years imprisonment and $150,000 fines. New Jersey's complex managed care landscape involving five competing MCOs across dense urban populations and the state's aggressive enforcement approach through joint federal-state operations creates heightened compliance risks where verification mistakes can trigger devastating multimillion-dollar settlements and criminal prosecution, with excluded providers prohibited from receiving reimbursement for NJ FamilyCare services in any capacity across one of the nation's most aggressively prosecuted and highest-recovery Medicaid fraud jurisdictions operating under enhanced federal oversight.
The New Mexico Department of Justice operates the state's Medicaid Fraud and Elder Abuse Bureau (MFEAB), also known as the Medicaid Fraud Control Unit, within the Special Investigations Division working in coordination with the New Mexico Health Care Authority's Office of Inspector General to investigate Medicaid fraud and provider misconduct across New Mexico's Centennial Care Medicaid program serving over 950,000 beneficiaries through a managed care structure involving multiple health plans across the state's challenging geographic terrain spanning 121,000 square miles. Healthcare employers must verify prospective employees against New Mexico's excluded provider list maintained by the Health Care Authority through coordination with the Attorney General's enforcement actions, as New Mexico maintains separate state exclusion records that federal OIG searches do not capture. New Mexico requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Centennial Care fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, prescription fraud involving dangerous opioids and narcotics, and whistleblower violations under New Mexico's aggressive enforcement structure targeting mental health providers and pain management physicians. New Mexico's vast rural geography serving vulnerable Native American populations across tribal lands, combined with recent federal enforcement actions resulting in over $1.6 million in fraudulent claims and identity theft prosecutions, creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions and criminal prosecution across one of the Southwest's most geographically challenging but closely monitored Medicaid programs operating under enhanced federal oversight and corrective action requirements.
The New York State Office of the Medicaid Inspector General operates as an independent entity within the New York State Department of Health, reporting directly to the Governor, working in coordination with the New York State Attorney General's Medicaid Fraud Control Unit to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against New York's OMIG List of Restricted and Excluded Providers maintained through the online database search system, allowing up to 5 names per search, as New York maintains separate state exclusion records under 18 NYCRR § 515.3 and § 515.7 that federal OIG searches do not capture. New York requires ongoing monthly verification throughout employment (every 30 days) with mandatory checks against both state and federal databases, with OMIG receiving substantial enforcement funding and achieving significant recoveries while demonstrating aggressive prosecution capabilities across one of the nation's largest and most complex Medicaid programs. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, unacceptable practices under state regulations, and violations that can result in immediate claim denials and fund recovery actions. New York's complex managed care landscape involving sophisticated academic medical centers, extensive provider networks, and OMIG's unique authority to exclude providers for state-level unacceptable practices even before criminal conviction creates heightened compliance risks where verification mistakes can trigger automatic claim rejections, aggressive recoupment actions, and civil monetary penalties, with excluded providers prohibited from receiving reimbursement for New York State Medicaid services in any capacity across one of the nation's most aggressively monitored and highest-stakes Medicaid fraud control jurisdictions.
The North Carolina Department of Health and Human Services operates the Office of Compliance & Program Integrity (OCPI) with the goal to stop fraud, waste, and abuse in Medicaid, working in coordination with federal oversight to prevent excluded providers from participating in NC Medicaid. Healthcare employers must verify prospective employees against North Carolina's Provider Termination and Exclusion list, updated monthly by NCDHHS and maintained separately from federal databases, as North Carolina maintains separate state exclusion records that federal OIG searches do not capture. North Carolina requires ongoing verification throughout employment with OCPI receiving substantial federal and state funding to investigate provider misconduct, achieving significant enforcement outcomes through systematic targeting of billing fraud schemes, inappropriate prescribing patterns, and patient abuse cases that resulted in multiple high-profile prosecutions and civil settlements exceeding millions in recoveries. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, unbundling, double billing, kickbacks, and violations under North Carolina's False Claims Act with penalties including treble damages and mandatory exclusions from all state healthcare programs. North Carolina's recent enforcement actions include coordinated federal-state prosecutions against healthcare executives, systematic investigations of managed care fraud, and aggressive pursuit of personal care service billing irregularities, creating heightened compliance risks where verification mistakes can trigger automatic claim denials, aggressive recoupment actions, and exclusion proceedings across one of the nation's largest and most complex Medicaid managed care systems with multiple contracted health plans and extensive provider networks.
The North Dakota Office of the Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the North Dakota Department of Health and Human Services Medical Services Division Program Integrity Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct across North Dakota's Medicaid program serving over 85,000 beneficiaries through managed care organizations and fee-for-service arrangements. Healthcare employers must verify prospective employees against North Dakota's ND Medicaid Provider Exclusion List maintained by the Department of Health and Human Services and updated monthly to include both traditional providers and Qualified Service Providers (QSPs), as North Dakota maintains separate state exclusion records that federal OIG searches do not capture. North Dakota requires ongoing verification throughout employment with mandatory checks against both state and federal databases, with the MFCU receiving 90% federal funding from US DHHS and 10% state funding, demonstrating substantial enforcement capabilities for a state of its size. The state's exclusion categories include North Dakota Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double billing, unbundling, and violations under North Dakota Century Code Chapter 50-24.8. North Dakota's unique verification system for QSPs using name, date of birth, and last four digits of social security numbers (rather than National Provider ID numbers) creates additional compliance complexity where verification mistakes can trigger automatic claim denials and civil penalties, with excluded providers prohibited from receiving reimbursement for North Dakota Medicaid services in any capacity across one of the nation's most systematically monitored rural Medicaid programs operating under enhanced federal oversight.
The Ohio Office of the Attorney General operates the state's Medicaid Fraud Control Unit, working in coordination with the Ohio Department of Medicaid's Program Integrity Division to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Ohio's excluded provider list maintained by the Ohio Department of Medicaid through coordination with the Attorney General's enforcement actions, as Ohio maintains separate state exclusion records under Ohio Administrative Code 5160-1-17.2 that federal OIG searches do not capture. Ohio requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Ohio Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, upcoding, double billing, kickback schemes, and violations under Ohio Revised Code Chapter 2913.40 with felony penalties up to 18 months imprisonment and $5,000 fines. Ohio's complex managed care landscape involving multiple health plans across urban and rural populations, combined with the state's aggressive enforcement approach through joint federal-state task forces targeting controlled substance diversion and fraudulent billing schemes involving nursing homes and home health agencies, creates heightened compliance risks where verification mistakes can trigger automatic claim denials, civil monetary penalties up to $10,000 per violation, recoupment of all payments made for services rendered by excluded individuals, and potential termination from Ohio Medicaid participation agreements across one of the Great Lakes region's most closely monitored and aggressively prosecuted Medicaid fraud control jurisdictions.
The Oklahoma Office of the Attorney General operates the state's Medicaid Fraud Control Unit in coordination with the Oklahoma Health Care Authority's Program Integrity Unit, creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Oklahoma's excluded provider list maintained by the Health Care Authority through coordination with the Attorney General's enforcement actions, as Oklahoma maintains separate state exclusion records that federal OIG searches do not capture. Oklahoma requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Oklahoma Medicaid fraud, patient abuse and neglect in long-term care facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double-billing, kickback schemes, and violations under Oklahoma's healthcare fraud statutes. Oklahoma's recent federal audit findings revealed opportunities for improvement in supervisory case review documentation and timely reporting of convictions to federal partners, creating heightened compliance risks where verification mistakes can trigger automatic claim denials and aggressive recoupment actions, with excluded providers prohibited from receiving reimbursement for SoonerCare services in any capacity across one of the nation's most federally scrutinized Medicaid fraud control programs.
The Oregon Health Authority operates its Program Integrity Audit Unit (PIAU) in coordination with the Oregon Department of Justice Medicaid Fraud Unit (MFU), creating a dual-agency enforcement structure for investigating Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Oregon's excluded provider list maintained by the Oregon Health Authority through coordination with the Department of Justice's enforcement actions, as Oregon maintains separate state exclusion records under Oregon Administrative Rules 410-120-1510 and 410-123-1025 that federal OIG searches do not capture. Oregon requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include OHP fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double billing, upcoding, phantom billing, and violations under Oregon's healthcare fraud statutes with automatic payment suspensions and recovery actions. Oregon's complex coordinated care organization structure, involving regional insurance companies managing provider networks, combined with recent state audit findings, creates heightened compliance risks where verification mistakes can trigger automatic claim denials, aggressive recoupment actions, and referrals to law enforcement across one of the Pacific Northwest's most closely monitored Medicaid programs operating under enhanced federal oversight.
The Pennsylvania Office of the Attorney General operates the state's Medicaid Fraud Control Section, working in coordination with the Pennsylvania Department of Human Services Bureau of Program Integrity to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Pennsylvania's Medicheck List maintained by the Department of Human Services and accessible through the online searchable database, as Pennsylvania maintains separate state exclusion records that federal OIG searches do not capture. Pennsylvania requires ongoing monthly verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Medical Assistance fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, and violations under Pennsylvania's healthcare fraud statutes with penalties including automatic claim denials and exclusion from all state healthcare programs. Pennsylvania's aggressive enforcement approach involving joint federal-state operations and the state's unique three-regional office structure spanning Western, Central, and Eastern regions creates heightened compliance risks where verification mistakes can trigger devastating recoupment actions and criminal prosecution, with excluded providers prohibited from receiving reimbursement for Medical Assistance services in any capacity across one of the nation's most successful and federally recognized Medicaid fraud control programs.
The Rhode Island Office of the Attorney General operates the state's Medicaid Fraud and Patient Abuse Unit, working in coordination with the Rhode Island Executive Office of Health and Human Services (EOHHS) to investigate Medicaid fraud and provider misconduct. Rhode Island does not maintain a separate state exclusion database, making it one of only seven states that rely exclusively on federal OIG exclusion reporting. Healthcare employers must verify prospective employees against federal databases only, as Rhode Island sanctions are reported directly to federal partners for inclusion in the national LEIE database rather than maintaining separate state records. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities, professional misconduct, criminal convictions related to controlled substances, and violations under Rhode Island General Laws Chapter 40-8.2, with recent federal oversight findings noting challenges with case file management and timely reporting of convictions to federal partners. Rhode Island's recent enforcement actions include investigations of Community Health Worker program fraud with referrals to both the Attorney General's Fraud Unit and the U.S. Office of Inspector General, demonstrating active coordination between state and federal enforcement agencies despite the absence of a separate state exclusion database.
The South Carolina Office of the Attorney General operates the state's Vulnerable Adults and Medicaid Provider Fraud Unit (VAMPF, formerly the Medicaid Fraud Control Unit), working in coordination with the South Carolina Department of Health and Human Services (SCDHHS) Bureau of Compliance and Performance Review to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against South Carolina's excluded provider list maintained by SCDHHS, as South Carolina maintains separate state exclusion records that federal OIG searches do not capture. South Carolina requires ongoing verification throughout employment with mandatory checks against both state and federal databases. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, vulnerable adult exploitation, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double billing, kickback schemes, and violations under South Carolina's healthcare fraud statutes, with federal oversight findings noting challenges with case file management documentation and timely reporting of convictions to federal partners. South Carolina's aggressive enforcement approach, involving participation in national multi-district healthcare fraud operations and the state's commitment to recovering funds lost, creates heightened compliance risks where verification mistakes can trigger automatic claim denials, civil monetary penalties, and aggressive recoupment actions.
The South Dakota Office of the Attorney General operates the state's Medicaid Fraud and Abuse Network Section (Medicaid FANS), working in coordination with the South Dakota Department of Social Services to investigate Medicaid fraud and provider misconduct. South Dakota does not maintain a separate state exclusion database, making it one of only seven states that rely exclusively on federal OIG exclusion reporting. Healthcare employers must verify prospective employees against federal databases only, as South Dakota sanctions are reported directly to federal partners for inclusion in the national LEIE database rather than maintaining separate state records. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities receiving federal funding, misappropriation of property from vulnerable residents, professional misconduct, criminal convictions related to controlled substances, billing for services not performed, double billing, upcoding, kickback schemes, and violations under South Dakota's healthcare fraud statutes. South Dakota's Medicaid FANS unit is responsible for heightened compliance risks where verification mistakes can trigger automatic claim denials, aggressive recoupment actions, and federal exclusion recommendations across a small-state Medicaid program.
The Tennessee Bureau of Investigation operates the state's Medicaid Fraud Control Division (TBI MFCD), working in coordination with TennCare's Office of Program Integrity and the Tennessee Attorney General's Civil Medicaid Fraud Division to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Tennessee's Terminated Provider List maintained by TennCare's Office of Program Integrity, as Tennessee maintains separate state exclusion records under TennCare policy requirements that federal OIG searches do not capture. Tennessee requires ongoing monthly verification throughout employment with mandatory checks against federal databases (HHS-OIG LEIE and GSA SAM) and the state TennCare Terminated Provider List. The state's exclusion categories include TennCare fraud, patient abuse and neglect in healthcare facilities receiving federal funding, financial exploitation of vulnerable adults, professional misconduct, fraud-related convictions, billing for services not performed, double billing, upcoding, unbundling of medical codes, kickback schemes, and violations under Tennessee Code Annotated 71-5-2508 and the Tennessee Medicaid False Claims Act. Tennessee's aggressive multi-agency enforcement approach involving the TBI MFCD, combined with annual recertification requirements by HHS-OIG and participation in national multi-state healthcare fraud cases, creates heightened compliance risks where verification mistakes can trigger automatic claim denials, provider agreement terminations with permanent placement on the state's Terminated Provider List, aggressive recoupment actions, referrals to the Tennessee Department of Health's Abuse Registry, criminal prosecution by federal and state authorities, and civil liability under the Tennessee Medicaid False Claims Act across one of the Southeast's most sophisticated and well-funded multi-jurisdictional Medicaid fraud control operations.
The Texas Office of the Attorney General operates the state's Medicaid Fraud Control Unit (MFCU), working in coordination with the Texas Health and Human Services Commission (HHSC) Office of Inspector General to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Texas's Exclusion List maintained by the HHSC Office of Inspector General and updated daily, as Texas maintains separate state exclusion records under Title 1, Texas Administrative Code, Chapter 371 that federal OIG searches do not capture. Texas requires ongoing monthly verification throughout employment with mandatory checks against both federal databases (HHS-OIG LEIE and GSA SAM) and the Texas Exclusion List, with failure to document compliance potentially resulting in administrative sanctions. The state's exclusion categories include Medicaid fraud convictions, patient abuse and neglect in healthcare facilities receiving Medicaid funding, licensing board adverse actions, Medicare program exclusions, billing for services not rendered or not medically necessary, illegal solicitation of clients, kickback schemes, forging documentation, and violations under Texas statutes with exclusion periods ranging from temporary to permanent. Texas's aggressive multi-jurisdictional enforcement structure involving the Attorney General's MFCU, combined with participation in national multi-state healthcare fraud operations, creates heightened compliance risks where verification mistakes can trigger recoupment of all payments made for excluded employees' services including salary and fringe benefits, provider termination, provider exclusion for up to 20 years, monetary penalties under 42 CFR 1003.102, and aggressive criminal prosecution across the nation's second-largest Medicaid program.
The Utah Office of the Attorney General operates the state's Medicaid Fraud Control Unit (MFCU), working in coordination with the Utah Office of Inspector General of Medicaid Services and the Utah Department of Health and Human Services to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against federal exclusion databases (HHS-OIG LEIE and GSA SAM), as Utah does not maintain a separate publicly accessible state exclusion list but coordinates sanctions through the Provider Sanction Committee under Utah Administrative Code R414-22. Utah requires ongoing monthly verification throughout employment with mandatory checks against federal databases, as the state refers exclusion recommendations directly to federal OIG for inclusion in the national LEIE database. The state's exclusion categories include Medicare or Medicaid fraud convictions, patient abuse and neglect in healthcare facilities receiving Medicaid funding, financial exploitation of vulnerable adults, licensing restrictions from the Division of Professional and Occupational Licensing (DOPL), felony convictions relating to controlled substances, billing for services not performed, kickback schemes, and provider misconduct creating substantial risk to program integrity with exclusion determinations made by the Provider Sanction Committee subject to CMS waiver approval for community access considerations. Utah's enforcement structure involving the Attorney General's award-winning 16-member MFCU, the Office of Inspector General, and participation in national healthcare fraud operations, creates heightened compliance risks where verification mistakes can trigger civil monetary penalties for employing excluded individuals, recoupment of all payments made for excluded employees' services, provider termination from managed care networks, and aggressive criminal prosecution across Utah's Medicaid program.
The Vermont Office of the Attorney General operates the state's Medicaid Fraud and Residential Abuse Unit (MFRAU), working in coordination with the Department of Vermont Health Access (DVHA) and the Agency of Human Services to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against Vermont's Medicaid Excluded Providers List maintained by the Department of Vermont Health Access and the Agency of Human Services, as Vermont maintains separate state exclusion records that federal OIG searches do not capture. Vermont requires ongoing monthly verification throughout employment with mandatory checks against both federal databases (HHS-OIG LEIE and GSA SAM) and Vermont's state-maintained excluded provider list available through DVHA. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, neglect of vulnerable adults in residential care settings, financial exploitation, professional misconduct, billing for services not performed, false documentation, failure to maintain required treatment records, refusal to provide records to state investigators, upcoding schemes, and violations under the Vermont False Claims Act with civil penalties of three times the amount defrauded plus mandatory penalties for each false claim. Vermont's aggressive enforcement approach involving MFRAU, recent federal oversight inspection findings, participation in national healthcare fraud operations, and high-profile civil enforcement actions creates heightened compliance risks where verification mistakes can trigger automatic provider termination from Vermont's Accountable Care Organization networks. They can trigger a recoupment of all payments made for excluded employees' services, civil liability under the Vermont False Claims Act with treble damages, referral to the Office of Professional Regulation for licensing sanctions, and criminal prosecution across Vermont's Medicaid program.
The Virginia Office of the Attorney General operates the state's Medicaid Fraud Control Unit (MFCU), working in coordination with the Department of Medical Assistance Services (DMAS) and the Agency of Human Services to investigate Medicaid fraud and provider misconduct. Virginia does not maintain a separate publicly accessible state exclusion database, making it one of only seven states that rely exclusively on federal OIG exclusion reporting. Healthcare employers must verify prospective employees against federal databases only (HHS-OIG LEIE and GSA SAM), as Virginia sanctions are reported directly to federal partners for inclusion in the national LEIE database rather than maintaining separate state records. Virginia requires ongoing monthly verification throughout employment with mandatory checks against federal databases, with providers required to immediately report any exclusion discoveries to DMAS Program Integrity/Exclusions. The state's exclusion categories include Medicaid fraud under Virginia Code § 32.1-314, patient abuse and neglect in healthcare facilities receiving federal funding, professional misconduct involving false statements or material misrepresentations in reimbursement applications, billing for services not performed or of lower quality, double billing and upcoding schemes, kickback violations under Virginia Code § 32.1-315, fraudulent schemes involving substitution or misrepresentation of items billed, and felony convictions requiring provider agreement relinquishment within 30 days under § 32.1-325. Virginia's award-winning enforcement structure involving the nationally recognized MFCU, aggressive civil enforcement under the Virginia Fraud Against Taxpayers Act with treble damages, and participation in multi-state healthcare fraud operations, creates heightened compliance risks where verification mistakes can trigger provider agreement termination with exclusion periods determined by DMAS, civil monetary penalties, mandatory restitution orders, criminal prosecution, and aggressive recoupment actions across Virginia's Medicaid program.
The Washington Office of the Attorney General operates the state's Medicaid Fraud Control Division (MFCD), working in coordination with the Health Care Authority (HCA) and the Department of Social and Health Services (DSHS) to investigate Medicaid fraud and provider misconduct. Washington is one of the few states that maintains two separate state exclusion databases: healthcare employers must verify prospective employees against both the Washington HCA Provider Termination and Exclusion List and the Washington DSHS Provider Termination and Exclusion List (updated regularly), as Washington maintains separate state exclusion records under WAC 182-502-0030 and RCW chapters 74.66 and 74.67 that federal OIG searches do not capture. Washington requires ongoing monthly verification throughout employment with mandatory checks against federal databases (HHS-OIG LEIE and GSA SAM) and both state-maintained exclusion lists. The state's exclusion categories include Medicaid fraud under the Washington Medicaid Fraud False Claims Act, patient abuse and neglect in nursing homes, adult family homes, and assisted living facilities receiving federal funding, moral turpitude and sexual misconduct, exclusion from Medicare or any federally funded healthcare program, convictions relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct, dishonest or discreditable acts contrary to agency interests, misrepresentation or failure to disclose information during enrollment, billing for unnecessary medical procedures, failure to cooperate with agency investigations, civil or criminal findings of fraudulent or abusive billing practices, DOH licensing restrictions or limitations, medical malpractice claims constituting questionable treatment patterns, and violations under WAC 182-502-0030 with termination determinations subject to clear and convincing evidence standards. Washington's aggressive dual-agency enforcement structure involving the Attorney General's award-winning MFCD, participation in national multi-state healthcare fraud operations, civil enforcement under the Washington Medicaid Fraud False Claims Act with treble damages, creates heightened compliance risks where verification mistakes can trigger immediate provider enrollment termination, recoupment of all payments made for excluded employees' services, civil monetary penalties deposited into the Medicaid Fraud Penalty Account, criminal prosecution with substantial recoveries, and permanent placement on both state exclusion lists across Washington's Apple Health Medicaid program.
The West Virginia Office of the Attorney General operates the state's Medicaid Fraud Control Unit (MFCU), working in coordination with the Bureau for Medical Services (BMS) to investigate Medicaid fraud and provider misconduct. Healthcare employers must verify prospective employees against West Virginia's Medicaid Provider Sanctioned/Exclusion Lists maintained by the West Virginia Medicaid Management Information System (WVMMIS), as West Virginia maintains separate state exclusion records that federal OIG searches do not capture. West Virginia requires ongoing monthly verification throughout employment with mandatory checks against both federal databases (HHS-OIG LEIE and GSA SAM) and the state's WVMMIS exclusion list, with providers required to maintain printed documentation of OIG Exclusion List checks for each individual in personnel files for audit review. The state's exclusion categories include Medicaid fraud, patient abuse and neglect in healthcare facilities receiving Medicaid funding, financial exploitation of vulnerable adults, misappropriation of private patient funds by Medicaid-funded facilities, billing for services not performed, double billing, upcoding schemes, kickback violations, and violations under West Virginia healthcare fraud statutes with exclusion periods ranging from temporary to permanent. West Virginia's restructured enforcement approach creates heightened compliance risks where verification mistakes can trigger recoupment of all payments made for excluded employees' services by BMS, provider termination, permanent exclusion from West Virginia's Medicaid program, civil monetary penalties, criminal prosecution, and aggressive enforcement actions across one of Appalachia's most improved multi-jurisdictional Medicaid fraud control operations.
The Wisconsin Department of Justice operates the state's Medicaid Fraud Control and Elder Abuse Unit (MFCEAU), working in coordination with the Wisconsin Department of Health Services (DHS) Office of Inspector General to investigate Medicaid provider fraud and patient abuse and neglect in healthcare facilities. Wisconsin does not maintain a separate publicly accessible state exclusion database, making it one of only seven states that rely exclusively on federal OIG exclusion reporting. Healthcare employers must verify prospective employees against federal databases only (HHS-OIG LEIE and GSA SAM), as Wisconsin sanctions are reported directly to federal partners for inclusion in the national LEIE database rather than maintaining separate state records. Wisconsin requires ongoing monthly verification throughout employment with mandatory checks against federal databases. The state's exclusion categories include Medicaid fraud under Wisconsin state law, patient abuse and neglect in nursing homes and board and care facilities, financial misappropriation of vulnerable adults, provider billing fraud including phantom billing and double billing, medical record falsification, kickback schemes, upcoding and unbundling violations, and provider misconduct under federal healthcare fraud statutes with exclusion determinations coordinated through federal channels. Wisconsin's robust dual-enforcement structure involving both the DOJ MFCEAU and the DHS OIG, creates heightened compliance risks where verification mistakes can trigger aggressive civil and criminal prosecution, provider termination, permanent exclusion from Wisconsin's Medicaid program, and coordinated recoupment actions across one of the Midwest's most sophisticated multi-agency Medicaid fraud control operations.
The Wyoming Attorney General's Office operates the state's Medicaid Fraud Control Unit (MFCU), working in coordination with the Wyoming Department of Health Division of Healthcare Financing Program Integrity Unit to investigate Medicaid provider fraud and patient abuse and neglect in healthcare facilities. Healthcare employers must verify prospective employees against Wyoming's Provider Exclusion List maintained by the Wyoming Department of Health, as Wyoming maintains separate state exclusion records that federal OIG searches do not capture. Wyoming requires ongoing monthly verification throughout employment with mandatory checks against both federal databases (HHS-OIG LEIE and GSA SAM) and the state's Wyoming Provider Exclusion List. The state's exclusion categories include Medicaid fraud involving intentional deception or misrepresentation for unauthorized benefits, patient abuse including hitting, shoving, nonconsensual sexual contact, and use of physical or chemical restraints, patient neglect involving deprivation of food, water, medications or medical services, misappropriation of patient funds in Medicaid-funded facilities, billing for services not performed, false documentation, and provider misconduct under Wyoming and federal healthcare fraud statutes with exclusion periods coordinated through both state and federal channels. Wyoming's compact but effective enforcement structure involving the Attorney General's small, specialized MFCU team creates heightened compliance risks where verification mistakes can trigger criminal prosecution, civil fraud actions, provider exclusion, recoupment of all payments made for excluded employees' services, and coordinated enforcement actions across Wyoming's Medicaid program.

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