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Patients of Medicare providers committing fraud or abuse more likely to be poor, disabled

Fraudulent medical practice is estimated to cost the federal government between $90 to $300 billion dollars annually.

Jeff Lagasse, Associate Editor

A new study from the Johns Hopkins Bloomberg School of Public Health analyzed providers excluded from Medicare for fraud and abuse, and found that the patients they treated prior to being banned were more likely to be minorities, disabled and dually-enrolled in Medicaid to supplement financial assistance for healthcare.

The findings, published in Health Affairs, highlight the risk that providers committing Medicare fraud and abuse could be taking advantage of their more vulnerable patients.

Medical fraud and abuse can include patient neglect, illegally providing prescription medications, unnecessary medical procedures, deceitful billing practices and using untrained personnel for direct patient care.

Fraudulent medical practice is estimated to cost the U.S. federal government between $90 to $300 billion dollars annually.

IMPACT

The researchers analyzed demographics of patients seen by excluded and non-excluded providers, taking into consideration the patient's location, age, and the type of provider. They found that not only were more patients more likely to be non-white - 27.4 percent versus 25 percent seen by non-excluded healthcare providers - they were also more likely to be dually-eligible for Medicaid by 38.8 percent versus 25.5 percent, and non-elderly disabled, 21.6 percent versus 17.3 percent.

The study took data from a list of excluded providers who were found to have committed fraud and abuse by the Office of the Inspector General of the Department of Health and Human Services. The list is updated monthly and the providers are identified through audits or criminal investigations.

During the study period, researchers identified 1,364 unique providers that were excluded for fraud and abuse. They classified excluded providers based on the first reason for exclusion, finding that 606, or 44 percent of providers, were excluded for fraud; 505, or 37 percent, for revoked licenses; and 253, or 19 percent, for patient harm. The excluded providers treated over 1.2 million beneficiaries during the study period and received $634 million in Medicare payments.

Providers excluded for fraud had the largest percentage of non-white and Medicaid dual-eligible patients, at 29.5 percent and 44.1 percent, respectively. Providers excluded for patient harm or revoked licenses were more likely to have patients under 65, disabled and dual-eligible for Medicaid. Disabled patients are 23-26 percent more likely to be treated by a provider excluded for fraud and abuse than someone treated by a non-excluded provider.

THE TREND

In August 2018 The Department of Justice announced a new regional Medicare fraud strike force for the Newark, New Jersey and Philadelphia, Pennsylvania region. Currently there is a Medicare fraud strike force in 10 cities across the United States: Miami, Florida; Los Angeles, California; Detroit, Michigan; Houston, Texas; Brooklyn, New York; Baton Rouge and New Orleans, Louisiana; Tampa, Florida; Chicago, Illinois; and Dallas, Texas.

As of last year, prosecutors in the 10 Medicare fraud strike force locations had charged over 3,700 defendants who collectively have falsely billed the Medicare program for over $14 billion.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com

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