Family medicine

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 health care.

Health analyzed providers

The findings; published in the May issue of 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 estimate to cost the U.S. federal government between $90 to $300 billion dollars annually. “Although fraud and abuse are know to be problems in Medicare, there have been no studies of the patients expose to the perpetrators;” explains lead author Lauren Hersch Nicholas, PhD; assistant professor in the Bloomberg School’s Department of Health Policy and Management.

Health Policy and Management

“Over a four-year period; we find that more than one million Medicare beneficiaries are treat by providers who are taking actions that could jeopardize patient health.” The researchers analyze demographics of patients see by excluded and non-exclude 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% versus 25% seen by non-excluded health care providers; they were also more likely to be dually-eligible for Medicaid, 38.8 percent versus 25.5%, and non-elderly disabled, 21.6% versus 17.3%.

The study took data from a list of excluded providers who are find to have committed fraud and abuse by the Office of the Inspector General of the Department of Health and Human Services. Therefore The list is updated monthly and the providers are identified through audits or criminal investigations. The researchers linked the list of excluded providers to their Medicare fee-for-service patients from 2012-2015 and compared them to beneficiaries being treated by non-fraudulent health care providers during the same time period.

Health care providers

During the study period, researchers identify 1,364 unique providers that are exclude for fraud and abuse. Because They classified exclude providers base on the first reason for exclusion; finding that 606, or 44% of providers, are exclude for fraud; 505, or 37%; therefore for revoked licenses and 253; or 19%, for patient harm. The exclude 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%t and 44.1%, respectively. Because Providers exclude for patient harm or revoke licenses were more likely to have patients under 65; disabled and dual-eligible for Medicaid. Disabled patients are 23-26% more likely to be treat by a provider exclude for fraud and abuse than someone treat by a non-exclude provider.