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.

Understanding the types of fraud in claims to South African medical schemes

“…Nortjé and Hoffmann's [12] study found that fraudulent activities committed by SA healthcare professionals consisted mainly of billing for false claims, which are similar to the findings of this study. Syndicate fraud committed through identity theft and the submission of fictitious claims was identified in this study, which is in line with the findings of Flynn, [10] Pande and Maas [20] and Nortjé and Hoffmann. [12] Our study also found that unlicensed people pose as healthcare service providers.…”

Sex differences in medico-legal action against doctors: a systematic review and meta-analysis

“…Criminal cases were examined in 2/32 studies [ 36 , 37 ]; both found that male doctors were significantly more likely to experience criminal charges ( P <0.05).…”

“…Overall, 27/32 studies found that male doctors were more likely to have had experienced at least one medico-legal action [ 5 – 7 , 13 , 14 , 16 – 19 , 21 – 23 , 25 – 28 , 30 , 32 – 39 ], although 4/27 studies did not calculate inferential statistics and did not provide sufficient data to enable the calculation of any effect size [ 13 , 18 , 32 , 38 ]. Of the studies that provided an effect size or where it was possible to calculate an effect size from the data reported, 22/23 demonstrated that male doctors were statistically significantly more likely to have had experienced a medico-legal action ( P ≤0.05) [ 5 – 7 , 14 , 16 , 17 , 19 – 23 , 25 – 28 , 30 , 31 , 33 – 37 , 39 ]. The remaining study examined doctors at two separate time intervals finding a significant association at the early time point only [ 31 ].…”

“…Of the 32 studies included in the systematic review, 19 reported data that allowed the calculation of a measure of effect and were included in the meta-analysis [ 5 , 6 , 8 , 9 , 14 , 16 , 19 , 20 , 22 – 25 , 28 , 31 , 34 – 37 , 39 ]. The meta-analysis included 3,794,486 study participants (both cases and non-cases), of which 20,666 are cases of medico-legal action.…”

Big Data fraud detection using multiple medicare data sources

“…The OIG has authority to exclude individuals and entities from federally funded healthcare programs, such as Medicare. Unfortunately, the LEIE is not all-inclusive where 38% of providers with fraud convictions continue to practice medicine and 21% were not suspended from medical practice despite their convictions [51]. Moreover, the LEIE dataset only contains the NPI values for a small percentage of physicians and entities.…”