Abstract
Each year, billions of dollars are wasted owing to health care fraud, waste, and abuse. Efforts to detect fraud have been increasing, yet we have little information about physicians who have been excluded from Medicare and state public insurance programs for fraud, health crimes, or the unlawful prescribing of controlled substances. To examine the characteristics of physicians excluded from Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances. This cross-sectional study considered all physicians excluded from Medicare and state public insurance programs between 2007 and 2017. The study matched exclusion data to a comprehensive, cross-sectional database of US physicians assembled by Doximity, an online networking service for US physicians. The share of physicians excluded in each state was examined and linear trends of exclusions over time were estimated. Using physician-level multivariable logistic regression models, exclusions (binary variable) were assessed as a function of physician characteristics. Exclusions for fraud, health crimes (defined legally as criminal penalties for acts involving federal health care programs), and substance abuse; and physician characteristics, including age, sex, allopathic vs osteopathic degree, medical school attended, ranking of that medical school, medical school faculty affiliation, practice state, practice location, and specialty. Between 2007 and 2017, 2222 physicians (0.29%) were temporarily or permanently excluded from Medicare and state public insurance programs. Fraud, health crimes, and substance abuse exclusions increased, on average, 20% per year (equivalent to 48 [95% CI, 40.4-56.0] convictions/year from a base of 236 convictions in 2007 to 670 convictions in 2017 [an increase of approximately 200% from 2007 to 2017]). Exclusion rates were highest in the West and Southeast. West Virginia had the highest exclusion rate, with 5.77 exclusions per 1000 physicians (32 exclusions among 5720 physicians), while Montana had 0 exclusions during this period. Male physicians, physicians with osteopathic training, older physicians, and physicians in specific specialties (eg, family medicine, psychiatry, internal medicine, anesthesiology, surgery, and obstetrics/gynecology) were more likely to be excluded. The number of physicians excluded from participation in Medicare and state public insurance reimbursement owing to fraud, waste, and abuse increased between 2007 and 2017. Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion. Our results highlight the potential value of using physician characteristics in conjunction with information on medical claims filed by physicians to help identify adverse physician behavior.
Highlights
Limited information exists on the characteristics of US physicians who have been excluded from Medicare and state public insurance programs for convictions of health care fraud, crimes related to health care delivery, or substance abuse
Data Sources and Study Sample We identified all physicians who were excluded from Medicare and state public insurance programs from 2007 to 2017 using data from the US Office of Inspector General, which has the right to exclude individuals and entities from public insurance participation for reasons specified in Section 1128 of the Social Security Act
Characteristics of Exclusions Physicians in the West and Southeast were most likely to be excluded for fraud, substance abuse, or health crimes (Figure 1)
Summary
Limited information exists on the characteristics of US physicians who have been excluded from Medicare and state public insurance programs for convictions of health care fraud, crimes related to health care delivery, or substance abuse. According to the Institute of Medicine, fraud, waste, and abuse in 2009 reached $750 billion (or 28% of total health care spending) with fraud alone constituting $75 billion (or 3% of total health care spending).[1] Other sources, including the Federal Bureau of Investigation, suggest that fraudulent billings have ranged up to $260 billion in 2010 (or 10% of total health care spending).[2,3] More recently, policymakers have taken several steps to reduce health care fraud, waste, and abuse, including establishing an interagency Medicare Fraud Strike Force in 2007 and laying forth provisions in the Patient Protection and Affordable Care Act (2010) and Small Business Jobs Act (2010) to prevent fraud and enable the prosecution of health care professionals who engage in fraudulent activities.[4,5,6]
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