Physician Medicare fraud: characteristics and consequences

Abstract

PurposeCriminal Medicare and/or Medicaid fraud costs taxpayers $60‐250 billion annually. This paper aims to outline the characteristics of physicians who have been convicted of such fraud.Design/methodology/approachThe names of convicted physicians were first gathered from public databases (primarily, the OIG exclusion list). The names were further cross‐checked and verified with other public records. Details regarding demographics and the particulars of the fraud were obtained by searching court documents, media reports, the internet, and records maintained by the American Medical Association and state medical licensing boards. The paper categorizes these doctors by: age, gender, geographic location, medical school attended, and medical specialty, and compares these demographics to those of the medical profession as a whole. The paper then identifies: the specific Medicare fraud these physicians were charged with; length of prison sentence and/or probation imposed; amount of fines assessed and/or restitution ordered; and professional sanctions imposed.FindingsPhysicians convicted of criminal Medicare and/or Medicaid fraud tend to be male (87 percent), older (average age of 58), and international medical graduates (59 percent). Family practitioners and psychiatrists are overrepresented. The amount of fraud averaged $1.4 million per convicted physician. Surprisingly, despite the fact that 40 percent of such fraud compromised patient care and safety, 37 percent of physicians convicted of felony fraud served no jail time, 38 percent of physicians with fraud convictions continue to practice medicine, and 21 percent were not suspended from medical practice for a single day despite their fraud convictions.Practical implicationsThe paper makes several practical recommendations including: running as many claims as possible through predictive modeling software to detect fraud before claims are paid; developing metrics on the average rate of diagnoses and procedures by specialty to be used in the predictive modeling software; incorporating the basics of ethical billing and the consequences of fraud convictions into the medical school curriculum and testing this knowledge on the USMLE; and encouraging and/or pressuring state medical boards to hold physicians more accountable for fraud.Originality/valueThe paper categorizes doctors convicted of Medicare and/or Medicaid fraud and makes specific recommendations regarding physician training, licensing and discipline, to reduce the amount of Medicare fraud perpetrated by doctors in the future.