Physician Exclusions From Medicare, Medicaid Increasing

Kerry Dooley Young

December 14, 2018

Federal efforts to detect Medicare fraud may be driving an increase in the number of physicians excluded from Medicare and other forms of public insurance, according to the authors of a newly published study.

The number of physicians excluded from Medicare, Medicaid, and other state public insurance programs increased on average by 20% per year, or the equivalent of 48 additional cases a year, between 2007 and 2017, said Anupam B. Jena, MD, PhD, of Harvard Medical School and colleagues. They report their findings in an article published online today in JAMA Network Open.

"There were several explanations for the observed increase in exclusions, and rates of identified health care fraud, waste, and abuse," Jena and colleagues write. "First, this finding could be evidence that regulators, who have been aided by recent public policies targeting the reduction of fraud and waste, may be getting better at identifying perpetrators of fraudulent activity."

Since 2011, the Centers for Medicare & Medicaid Services has used predictive analytics to detect improper billing, the authors note. In addition, the Affordable Care Act of 2010 allocated $350 million to the Department of Health & Human Services' Health Care Fraud and Abuse Control Account. The law also increased sanctions, including allowing state Medicaid programs to halt payments and requiring that Medicare overpayments be returned within 60 days instead of 3 years.

Jena and colleagues also cite the growth in the total number of US physicians participating in public insurance as a possible cause for the rising number of exclusions.

The implementation of the Affordable Care Act of 2010 allowed more people to gain access to public insurance programs. Enrollment in any government health insurance plan increased by 12.6% total from 2013 to 2017, which is significantly greater than the 7.9% increase in private insurance enrollment, the authors note.

"We cannot exclude the possibility that the increase in physician exclusions reflects a rise in fraudulent and untoward practices by US physicians," the authors add. "However, we are unaware of any published data that support this potential explanation."

Overall, the researchers found that 2222 physicians, or 0.3% of US physicians, were temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017 for fraud, unlawful prescribing of controlled substances, or health crimes.

Physicians can be excluded from Medicare and other public insurance programs for a variety of reasons. Common causes include the illegal distributing, prescribing, and dispensing of controlled substances such as opioids and surgical anesthetics. Other reasons include billing for services not rendered and filing duplicate claims and providing medically unnecessary procedures.

Jena and colleagues describe their study as "the most comprehensive and contemporary effort to assess trends in physician exclusion from participation in public health insurance owing to fraud, waste, and abuse concerns, and physician characteristics associated with exclusion."

For the analysis, they matched each physician's unique national provider identifier to their profile in Doximity, an online networking service that collects personal and professional information about physicians.

The authors found notable variation in the rates of exclusion, which were highest in the West and Southeast. With 32 exclusions among 5720 physicians, West Virginia had the highest rate of exclusions at 5.77 per 1000. Montana, in contrast, had 0 exclusions during the study period.

"Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion," the authors said.

This project was funded by National Institutes of Health grants. Jena also reported having received consulting fees from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis, Amgen, Eli Lilly, Vertex Pharmaceuticals, AstraZeneca, Celgene, Tesaro, Sanofi Aventis, Biogen, Precision Health Economics, and Analysis Group outside the work reported in the paper.

JAMA Network Open. Published online December 14, 2018. Full text

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