Limited information exists on the characteristics of US physicians who have been excluded from Medicare and state public insurance programs for convictions of health care fraud, crimes related to health care delivery, or substance abuse.

Common fraud schemes include billing for services not rendered, filing duplicate claims (including the unbundling of bundled services), and misrepresenting dates and locations where services were provided. Health crimes involve the provision of medically unnecessary procedures, illegal patient admittance and retention practices, the making of false statements (including physician medical identify theft), and the gross violation of professionally recognized standards of care.

Researchers decided to to examine the characteristics of physicians excluded from Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances. Alice Chen, PhD, MBA, from the University of Southern California in Los Angeles, and colleagues conducted a cross-sectional study to examine the characteristics of physicians excluded from Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances between 2007 and 2017.

“We found that the number of physicians excluded from participating in public health insurance has grown substantially over time and that excluded physicians were concentrated in specific regions of the United States,” the authors write.

The researchers found that 2222 physicians were temporarily or permanently excluded from Medicare and state public insurance programs during 2007 to 2017. On average, there was a 20% increase per year in fraud, health crimes, and substance abuse exclusions (from 236 convictions in 2007 to 670 in 2017). Researchers found the highest exclusion rates in the West and Southeast. The state with the highest exclusion rate was West Virginia, with 5.77 exclusions per 1000 physicians, while there were no exclusions in Montana. Exclusions were more likely for male physicians, physicians with osteopathic training, older physicians, and physicians in specific specialties.

Physicians in the West and Southeast were most likely to be excluded for fraud, substance abuse, or health crimes. Although California, New York, Florida, and Texas had the highest absolute counts of excluded physicians from 2007 to 2017, they also had the largest physician populations.

When considering the rate of physician exclusions per 1000 physicians, only Florida remained in the highest category of exclusion rates. West Virginia had the highest exclusion rate, with 5.77 exclusions per 1000 physicians (32 exclusions among 5720 physicians), while Montana had 0 exclusions during this period.

There were several explanations for the observed increase in exclusions, and rates of identified health care fraud, waste, and abuse. First, this finding could be evidence that regulators, who have been aided by recent public policies targeting the reduction of fraud and waste, may be getting better at identifying perpetrators of fraudulent activity.

Physician exclusions were more common in certain states in the West and Southeast. Many of these regions had Medicare Fraud Strike Force Teams, which were established in “hot spots” of unexplained high Medicare billing levels (Florida, California, Michigan, Texas, New York, Louisiana, Florida, and Illinois as of 2017).

In addition, the growth in physician exclusions could also be due, at least in part, to growth in the total number of US physicians participating in public insurance.