Study: Patients treated by fraudulent providers often most vulnerable

File folders labeled "insurance," "fraud," "claims," and "under investigation"
A new study dives into population dynamics among patients treated by fraud and abuse perpetrators. (Getty Images/Olivier Le Moal)

Between 2012 and 2015, 1.2 million Medicare beneficiaries were treated by providers who committed fraud or abuse—and many of these patients were from vulnerable populations, according to a new study. 

Researchers led by a team at Johns Hopkins studied the demographics of these beneficiaries and found that 28% were under age 65 and disabled and about 45% were dually eligible for Medicaid. 

In addition, many were nonwhite. About 16% of those treated by fraud and abuse perpetrators were black, 10% were Asian, 5% were Hispanic and about 7% were from other ethnic or racial groups, according to the study. 

Lauren Nicholas, an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public health and the study’s lead author, told FierceHealthcare that the team went into the study with an expectation that these “less savory healthcare providers” may be treating such patients. 

“It’s not entirely surprising that these providers are, in fact, preying on some of the most vulnerable patients, but it’s disheartening to have some of those fears confirmed,” she said. 

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Fraud and abuse perpetrators also treat these vulnerable Medicare patients at higher rates than other providers, according to the study. For example, 25% of patients treated at providers who did not engage in this behavior were dual-eligible, compared to nearly 45%. 

The researchers also adjusted calculations to see if other factors, such as location or specialty, impacted the trends, and found that the trends held. After that additional analysis, for example, the study shows that about 27% of patients treated by fraud and abuse perpetrators were nonwhite, compared to 25% for other providers. 

Nicholas said she and the other researchers involved with the study decided to conduct the investigation from a “human interest” point of view, as egregious tales of fraud and abuse aren’t rare headlines.  

However, data on which patients are caught up in these schemes is scant. Hopefully, these findings can open the door for a “much longer research agenda,” including studies that go beyond Medicare data and look at commercial payers and Medicaid as well, she said. 

That fraud and abuse perpetrators treated more than a million patients in such a short window, regardless of demographics, suggests the problem is much larger when you look beyond one payer, Nicholas said. 

“It’s likely much worse when you think about private health insurance or Medicaid,” she said. “We’re just sort of scratching the surface in terms of understanding what a big problem it is.”