Fraud, waste, and abuse in our healthcare system is rampant. It is estimated that between $30 to $140 billion dollars represent fraudulent medical practices annually. These concerns have long been scrutinized from a financial standpoint, but new studies suggest it also represents a major public health threat to patients.
#MedicalCoding #MedicalBilling #Compliance #Revenue #RevenueCycle #RevenueCycleManagement #AlphaCodingExperts #AAPC #AHIMA #Coders #Auditors #Physicians #HIM #CDI #RevenueIntegrity #CMS #Fraud #Abuse #Medicare
Medicare fraud and abuse linked to patient deaths and hospitalizations
Originally posted on Medical Press
By: Johns Hopkins University Bloomberg School of Public Health
Patients treated by health care professionals later excluded from the Medicare program for committing fraud and abuse were between 14 to 17 percent more likely to die than similar patients treated by non-excluded physicians, nurses, and other professionals, according to a new study from researchers at Johns Hopkins Bloomberg School of Public Health.
The study estimates that fraud and abuse contributed to 6,700 premature deaths in 2013 alone.
The findings will be published on October 28 in JAMA Internal Medicine.
The study also found that patients treated by providers later banned from Medicare for fraud and abuse were 11 to 30 percent more likely to experience an emergency hospitalization in the year of exposure. The study found that providers later banned for fraud and abuse treated patients who were more likely to be low-income, non-white, and under-65 disabled.
More than 47,000 health care professionals have been banned from Medicare and Medicaid, federal programs that provide health insurance to elderly, disabled, and low-income beneficiaries, because of fraud and abuse. Medical fraud and abuse can involve patient neglect, illegally providing prescription medications, unnecessary medical procedures, deceitful billing practices, practicing without a license and/or using untrained personnel for direct patient care. Fraudulent medical practice is estimated to cost the U.S. federal government between $30 to $140 billion dollars annually.
"We found that even a single visit with a provider later excluded for fraud and abuse increased the risk of dying compared to someone who lived in the same county and had the same health status but did not see an excluded provider," says lead author Lauren Hersch Nicholas, Ph.D., assistant professor in the Bloomberg School's Department of Health Policy and Management. "While fraud has traditionally been viewed as a financial concern, our study shows that it also represents a major public health threat to patients."
For their study, the researchers analyzed the list of providers excluded from Medicare for fraud and abuse maintained by the U.S. Department of Health and Human Services' Office of the Inspector General's List of Excluded Individuals between 2012 and 2018. The list identifies excluded providers through audits or criminal investigations. For their analysis, researchers linked the list of excluded providers to a random sample of the Medicare patients treated by excluded providers.
The study sample included 8,204 Medicare patients who were first treated by a provider later banned for fraud and abuse in 2013 and a comparison group of 296,298 patients treated by a randomly selected provider who had not been banned for fraud and abuse. Prior to the fraud and abuse exposure, the two groups were in similar health. The researchers followed patients for up to three years to study differences in mortality and hospitalization.
Nearly one-quarter—23 percent—of patients seen by excluded providers in the study were non-white while approximately 16.5 percent of patients treated by non-excluded providers were non-white. Compared to patients treated by non-excluded providers, patients treated by providers committing fraud and abuse were more likely to be disabled, 27.2 versus 18.6 percent; and dually enrolled in Medicare and Medicaid, 34.7 percent versus 21.9 percent.
Nicholas notes that fraud and abuse disproportionately impact minority communities and may exacerbate health disparities.
Researchers classified excluded providers based on their first reason for exclusion across three broad categories. More than 60 percent of patients in the sample were treated by providers found to be committing fraud. Broken down, 14 percent of patients were treated by providers who had committed patient harm, and 24 percent were treated by providers practicing with a revoked license.
The study found that providers excluded for fraud were associated with the highest mortality rate; these patients were 17.3 percent more likely to die than patients not treated by an excluded provider. Patients who were treated by providers excluded for patient harm were 13.7 percent more likely to die, and patients who were treated by providers excluded for revoked licenses were 14.8 percent more likely to die.
"Sadly, provider fraud and abuse affects some of our most vulnerable patients," says Nicholas. "If we can find and remove providers committing fraud and abuse more quickly, we can save patient lives, improve health outcomes, and prevent unnecessary spending."
"Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries" was written by Lauren Hersch Nicholas, Caroline Hanson, Jodi B. Segal, and Matthew Eisenberg.