Arrests, sanctions didn't stop doctors from getting Medicare dollars

In 2012, CMS paid at least $6 million to sanctioned physicians

Dozens of physicians who received Medicare payments in 2012 had been thrown out of state Medicaid programs, been indicted or charged with fraud, or even settled allegations of overbilling Medicare itself, according to a ProPublica analysis of recently released doctor payment data.

The analysis of payments made under Medicare Part B, which was released last week for the first time in 35 years, revealed that outlays to sanctioned health care providers exceeded $6 million in 2012. ProPublica's Charles Ornstein offers a look are some of the physicians who continued to collect from the agency after being flagged by law enforcement or other oversight agencies:

  • Pain doctor Lawrence Eppelbaum was indicted in March 2011 on charges of incenting patients to be treated at his Roswell, Ga., clinic by paying their travel expenses through a charity he controlled. Medicare paid Eppelbaum $500,000 to treat 80 patients in 2012.
  • Michigan ophthalmologist Matthew Burman was suspended from the state's Medicaid program in 2009 after being convicted of criminal sexual misconduct. Three years later, Medicare paid Burman $379,000.
  • Louisville physician Steven Stern and his practice paid $350,000 to settle allegations of overbilling Medicare in 2011. Specifically, Stern was accused of splitting vials of the rheumatoid arthritis drug Infliximab and billing Medicare as if a full vial was used for each patient. He received $3 million from Medicare in 2012, including $2 million for Infliximab infusions.
  • New Orleans physician Anthony Jase pleaded guilty on two counts of Medicare fraud in October 2011, but he was paid $97,460 in Medicare reimbursement in 2012. Last year, he was sentenced to 15 months in prison and ordered to pay more than $360,000 in restitution.

Though the $6 million sum represents only a small fraction of the total $77 billion Medicare paid out in 2012, former and current federal officials and fraud experts say the oversight epitomizes regulators' inability to protect the program and patients from fraud and abuse.

"If you've been suspended or terminated in one of the federal programs...I would think that you'd be suspended in the other programs, just as a basis of good practice," says Louis Saccoccio, CEO of the National Health Care Anti-Fraud Association. The public only gained access to the reimbursement data last week, but Medicare has long had access, and "[t]hey're the ones doing the paying," he notes.

A spotlight on Medicare's fraud-fighting efforts

Medicare's fraud-fighting efforts have been criticized frequently in recent years, ProPublica notes. In an audit last month, HHS found that one-third of states failed to report when they barred providers from Medicaid and others offered incomplete information, preventing regulators' from effectively tracking sanctioned providers.

In December, the agency was faulted for not systematically reviewing the practices of the top-paid doctors and urged that more be done to detect fraudulent claims. And last year, a ProPublica investigation found that doctors who had been kicked out of Medicaid or disciplined by state medical boards were able to continue prescribing drugs in Medicare's drug program. The report prompted Sen. Charles Grassley (R) to call for enhanced coordination.

ProPublica: Medicare wants to ban harmful prescribers

"There's been a disconnect between Medicaid and Medicare on problem providers," Grassley told ProPublica. "The release of Medicare billing data should help force better communication between Medicaid and Medicare on these providers. The new transparency makes it harder to ignore when doctors who harm patients or defraud taxpayers in one program face no consequences in the other program."

Medicare responds

Aaron Albright, a spokesperson for CMS, wrote in an email to ProPublica that preventing improper payments is a top priority for the agency. New enrollment screening techniques have been established to prevent providers from accessing the system and advanced data analytics are being used to spot fraudulent billing before they are paid out, Albright said. He added, "Already, we have cracked down on tens of thousands health care providers suspected of Medicare fraud."

Nonetheless, CMS principal deputy administrator Jonathan Blum acknowledged in a conference call that the agency should go to greater lengths to prevent fraud. He said, "We know there's waste in the system. We know there's fraud in the system. We want the public's help" to review the physician payment data and seek out providers who are billing improperly (Ornstein, ProPublica/NPR, 4/16).

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