Medicare Slow to Boot Physicians with State Sanctions
Written by Editor   
Monday, September 03, 2018 07:27 PM

Medical Physicians who land in hot water with state regulators have a helping hand when it comes to keeping their practices running:  The federal government.

At least 216 remained on Medicare payment rolls in 2015 despite surrendering a license, having one revoked, or being excluded from state-paid healthcare rolls in the previous five years this report found.  In all, they were paid $25.8 million by taxpayers in 2015 alone.

For example one medical physician surrendered his license in California rather than contest charges of sexual impropriety.  He continued to practice medicine in New York, however.  Taxpayers helped foot the bill for him to keep practicing medicine. In 2015, the year after he surrendered his California license, he was paid more than $280,000 through Medicare.  Other individual physicians who faced serious sanctions were paid as much as $1.4 million that year.

Medicare is part of the U.S. Department of Health and Human Services (HHS) -- the same department that operates the National Practitioner Data Bank, which tracks discipline against physicians, including sanctions by state medical boards.

The HHS Office of the Inspector General (OIG) is required to exclude physicians from payment rolls if they are convicted of several specific charges, such as abusing patients, defrauding the system, or are caught improperly prescribing controlled substances.  But there are 16 categories of problems where the OIG may choose not to exclude physicians, including failing to meet basic standards of care or even having a medical license revoked.

As a result, while more than 1,500 physicians had licenses suspended, revoked or put on probation in 2015 by state medical boards, only 305 were prohibited from billing Medicare that year.

Private insurance companies spend money to make sure they don’t pay more than needed, or support bad medicine, said Leslie Paige, vice president for policy and communications for Citizens Against Government Waste, a nonprofit watchdog group that lobbies for reduced government spending.  Medicare doles out far more money and isn’t even using the data the department already gathers on physicians’ problems, she said. "They need to do a better job of tracking these people down and stopping them before they abscond with taxpayer dollars or hurt patients," Paige said. “Seniors should not be sitting ducks for predators simply because they're on Medicare."

According to Todd Echols, who oversees the OIG’s program, workers managing exclusions can be overwhelmed by a flood of information about providers -- in part because computers are now involved.  For decades, the process was driven through relationships investigators forged with state medical boards. The state boards kept an eye out for cases that fit the criteria for exclusion from the federal system, then passed them along.

Last year, OIG started getting a data feed from the Federation of State Medical Boards. In the first year alone, the group sent more than 2,000 cases to investigate. The actions were a mix of positive and negative, and the vast majority didn’t meet the criteria for federal exclusion, a spokesman said.

Some exclusion authorities only come into play if a physician's behavior affected a patient on Medicare or Medicaid.

Echols said documents in such cases -- whether they be from state medical boards, court filings or other sources -- have to clearly indicate a relationship to those one of those two programs.

The problems must also match those in the federal law describing the exclusion process. For example, they have to document issues with "professional competence" or "financial integrity" to result in an exclusion.