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Related Experiment Videos

Fraud by physicians against Medicaid.

P Jesilow1, G Geis, H Pontell

  • 1Program in Social Ecology, University of California, Irvine 92717.

JAMA
|December 18, 1991
PubMed
Summary

The establishment of the Medicaid program led to increased physician fraud and abuse. Sanctioned physicians often blamed the program

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Area of Science:

  • Medical Economics
  • Healthcare Policy
  • Medical Ethics

Background:

  • The introduction of the Medicaid program in the mid-1960s created new avenues for illegal physician conduct.
  • Government payment systems, rather than patient responsibility, contributed to a rise in violations.
  • Analysis of sanctioned physicians revealed a disproportionate representation of psychiatrists, foreign medical graduates, and minority physicians.

Purpose of the Study:

  • To investigate the nature and contributing factors of physician fraud and abuse within the Medicaid program.
  • To understand the perspectives of physicians sanctioned for Medicaid violations.
  • To examine the conflict between physician autonomy and program regulations.

Main Methods:

  • Review of background information on physicians sanctioned for Medicaid fraud and abuse.
  • Interviews with physicians convicted of Medicaid fraud and abuse.

Main Results:

  • Sanctioned physicians frequently attributed their violations to program complexities, staff, patients, or external factors.
  • Physicians cited confusing and irrational program guidelines as impediments to independent medical judgment.
  • Enforcement officials contended that physicians' explanations were rationalizations for self-serving and avaricious conduct.

Conclusions:

  • Physician behavior within government-funded healthcare programs is influenced by program structure and perceived regulatory burdens.
  • Discrepancies exist between physicians' justifications for violations and enforcement agencies' interpretations of intent.
  • Understanding these dynamics is crucial for effective healthcare policy and fraud prevention.
Keywords:
Empirical ApproachHealth Care and Public HealthLegal ApproachMedicaid

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