The federal government kicked 1,134 health care providers out of the Medicare and Medicaid programs last year as part of a stepped-up effort to punish rule-breakers and save taxpayers' money.
The doctors, nurses and health care companies were suspended for violations ranging from failure to pay medical-school loans to submitting fraudulent bills for medical equipment to abusing nursing-home patients, a review of the cases shows.Their penalties ranged from suspensions of a few months to several years.
By booting the doctors, nurses and other medical professionals from the programs, the Health Care Financing Administration is denying them access to a lucrative source of income - the multi-billion-dollar Medicare and Medicaid markets.
"Exclusion is like a death sentence - you are out of business," said Jim Conrad, head of Medicare's benefit integrity division.
The 1995 total includes the first wave of providers caught in a crackdown on fraud begun by the Clinton administration in June. Called "Operation Restore Trust," the effort is aimed at the five states that account for 40 percent of the nation's Medicare and Medicaid beneficiaries.
Experts estimate that as much as one-tenth of the more than $1 trillion spent on health care each year is lost to fraud. Of that huge health care market, Medicare costs in 1995 were $177 billion and Medicaid cost the federal government $88 billion.
"With that much money at stake, the lure of a fast buck is irresistible to the hardened criminal as well as those who straddle the fence between honesty and dishonesty," June Gibbs Brown, inspector general for the Department of Health and Human Services, told a congressional panel last year.
Doctors and other providers who are excluded from the federal programs might still be allowed to practice if their license is in good standing with their state. The opposite is true, too - meaning if the federal government is slow to act against a bad doctor, the provider could continue to bill Medicare even after getting in trouble with a state licensing authority.
A computer-assisted study of the 1,134 providers excluded from Medicare and Medicaid uncovered these patterns:
- More than one-fourth - or 296 - of the 1,134 were providers who had not paid their medical school and college loans. (Because these providers can be reinstated almost immediately once they are current on their loans, the total in this category can fluctuate from day to day.)
- Fraud and excessive billing by physicians, nurses' aides and other medical providers accounted for about 330 of the removals.
- Two hundred seventy nurses and nurses' aides were excluded last year - more than any other specialty or profession. Of the 270, 118 were removed because their licenses were either suspended or revoked; 106 were convicted of patient abuse or neglect. Family physicians made up 167 of the exclusions, and chiropractors had 158 exclusions.
- Twenty-nine of the providers kicked out last year were involved in the durable medical equipment industry, which provides patients with everything from wheelchairs to prosthetics to oxygen equipment.
In recent years, this industry has been cited as a major source of fraud in the health care industry. Unscrupulous providers have been caught billing Medicare for items that were not authorized by a physician, or billing the government and then not providing the equipment. In some instances, they billed exorbitant rates for items not needed or not covered by Medicare.
The federal government often lags behind state and local authorities.
One problem is the length of time it takes to remove unscrupulous providers from the federal programs. Once a provider has been notified of the federal government's intent to exclude them, he or she has 60 days to request a hearing with an administrative law judge. These proceedings can take months.
Conrad, the head of Medicare's benefit-integrity division, acknowledges his work shows that some sanctioned providers make it back into the system. While assigning identification numbers to physicians has made it more difficult for sanctioned doctors to re-enter the system, there is currently no equivalent federal registry for nurses, nursing-home operators and equipment suppliers.
And there is a legal loophole that allows some doctors to continue to participate.
In some instances, providers who have been kicked out can receive a waiver that allows them to continue to participate in Medicare and Medicaid if a state can demonstrate a pressing need for their services. Only providers convicted of patient abuse or neglect are ineligible for such a waiver.
Nonetheless, the number of providers excluded from Medicare has increased in recent years.
Using data that include providers who have been both fined and kicked out, inspector general Brown said the number of sanctions imposed yearly has grown from 440 in fiscal 1987 to 1,334 in fiscal 1994 - an increase of more than 300 percent. Currently there are 8,567 providers excluded from the Medicare and Medicaid program.
If the first six weeks of 1996 are any indication, the trend will continue: As of mid-February, federal authorities had removed 136 providers.
But does the increase mean Operation Restore Trust is putting a dent in fraud? Conrad is not sure.
"We have more cases pending right now than ever before," Conrad said. "But are fewer cases happening? We don't know. We don't know if someone stepping in replaces someone we have just caught."
(Distributed by Scripps Howard News Service.)