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Rising Physician Exclusion from Medicare and Medicaid

JAMA Network Open has published that an increasing number of physicians are being excluded from Medicare and other forms of public insurance. 

Overall the authors found that the number of physicians excluded from Medicare, Medicaid, and other state public insurance programs increased on average by 20% per year between 2007 and 2017.

They found that 2222 physicians were temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017 for fraud, unlawful prescribing of controlled substances, or health crimes.

Since 2011, the Centers for Medicare & Medicaid Services has used predictive analytics to detect improper billing.  Under current law, these analyses can be used to levy sanctions, or halt payments and require Medicare overpayments to be returned immediately.

In addition to improper billing practices, physicans can be excluded from Medicare (and other programs) for illegal distributing, prescribing, and dispensing of controlled substances such as opioids and surgical anesthetics. 

Excluded physicians were more likely to be male, older, osteopaths and from certain regions. For instance, states in the West and Southeast had the highest rate. West Virginia had the highest rate of exclusions at 5.77 per 1000.

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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