Minorities and some of the most vulnerable Medicare beneficiaries — including people with a disability and low-income seniors — are more likely than others to be treated by providers who were later banned for fraud or abuse, according to a new study from the Johns Hopkins Bloomberg School of Public Health.
The research appeared in the May edition of Health Affairs.
Medicare fraud and abuse cost about $52 billion in fiscal 2017, according to the Government Accountability Office, and could become an even more unwieldy problem as Medicare spending continues to grow.
Patient neglect, unnecessary medical procedures, deceitful billing practices, and reselling medication are examples of fraud and abuse that can lead to a provider being banned from Medicare.
The Government Accountability Office has called on the Centers for Medicare and Medicaid Services to do more to curtail Medicare fraud.
This study aimed to better define the patients being cared for by fraudulent providers.
Researchers used lists of providers who have been excluded from Medicare because of fraud and abuse, compiled by the Office of the Inspector General of the Department of Health and Human Services. They linked providers on those lists to the original Medicare patients they saw between 2012 and 2015, before being banned from Medicare, and compared them with the patients of doctors who haven’t been banned.
The study was supported by a grant from the Social Security Administration, through its Disability Research Consortium.
During the study period, researchers found that 1,400 providers (doctors, nurses, physician assistants and social workers) who were later banned for fraud or abuse treated more than 1.2 million Medicare beneficiaries and received $630 million from Medicare.
Researchers compared the demographics of patients seen by providers who were eventually banned for fraud or abuse and those were weren’t. They found that patients treated by providers who were later banned from Medicare were disproportionately minority, eligible for both Medicare and Medicaid, and receiving benefits because of a disability.
Among providers later banned from Medicare, 39 percent of patients were dual-eligible for Medicaid, 32 percent were non-elderly disabled, and 27 percent were minorities.
By comparison, 26 percent of patients treated by law-abiding providers were dual-eligible for Medicaid, 17 percent non-elderly disabled, and 25 percent minority.
The study looked only at fraud and abuse among individual providers, not organization-level offenders, such as a home health agency, and patients with traditional Medicare, not those with Medicare Advantage plans. For these reasons, the number of Medicare beneficiaries treated by providers later excluded for fraud or abuse (and, subsequently, the amount spent on their care) is likely understated, researchers wrote.
The next steps
“We need more efforts to find fraud and abuse more quickly, to remove those providers from Medicare and also to improve our efforts to provide follow-up care to patients who we know have been impacted by these providers,” said Lauren Hersch Nicholas, the lead author and an assistant professor at the Bloomberg School’s department of health policy and management, in a statement. “Current efforts focus on recovering money from fraud and abuse and do not emphasize the patients being treated by these providers.”