Criminal Prosecution As A Deterrent To Health Care Fraud

Criminal prosecution as a deterrent to health care fraud : hearing before the Subcommittee on Crime and Drugs of the Committee on the Judiciary, United States Senate, One Hundred Eleventh Congress, first session, May 20, 2009.

Criminal prosecution as a deterrent to health care fraud: hearing before the Subcommittee on Crime and Drugs of the Committee on the Judiciary, United States Senate, One Hundred Eleventh Congress, first session, May 20, 2009.

In this explosive exposé of our health care system, Paul Jesilow, Henry N. Pontell, and Gilbert Geis uncover the dark side of physician practice. Using interviews with doctors and federal, state, and private officials and extensive investigation of case files, they tell the stories of doctors who profit from abortions on women who aren't pregnant, of needless surgery, overcharging for services, and excessive testing. How can doctors, recipients of a sacred trust and sworn to the Hippocratic Oath, violate Medicaid so egregiously? The authors trace patterns of abuse to the program's inauguration in the mid 1960s, when government authorities, not individual patients, were entrusted with responsibility for payments. Determining fees and regulating treatment also became the job of government agencies, thus limiting the doctors' traditional role. Physicians continue to disagree with Medicare and Medicaid policies that infringe on their autonomy and judgment. The medical profession has not accepted the gravity or extent of some members' illegal behavior, and individual doctors continue to blame violations on subordinates and patients. In the meantime, program guidelines have grown more confusing, hamstringing efforts to detect, apprehend, and prosecute Medicaid defrauders. Failure to institute a coherent policy for fraud control in the medical benefit program has allowed self-serving and greedy practitioners to violate the law with impunity. Prescription for Profit is a shocking revelation of abuse within a once-hallowed profession. It is a book that every doctor, and every patient, needs to read this year.

The concept of deviance is complex, given that norms vary considerably across groups, times, and places. Society tends to primarily recognize traditional portraits of deviants such as street-offenders and drug addicts. The label "deviant" is commonly cast upon society’s undesirables, but this socially constructed image often overlooks subtler—and arguably more dangerous—deviance. Physician malfeasance is an especially problematic form, given that medical professionals garner trust, autonomy, and prestige from society, which allows them to operate outside of the public eye. This book responds to a growing number of concerns regarding deviant physician actions such as physically and sexually abusive behaviors, fabricating medical findings and records, and taking advantage of patients (e.g., filing fraudulent Medicaid claims). It explores theoretical explanations for physician deviance, and goes on to consider potential responses such as Medicaid Fraud Control Units, the Questionable Doctors database, and the ability of doctors to police themselves. The unique perspective offered in this book informs discussions of white-collar crime and deviance and has important implications for researchers, policymakers, and students involved in criminal justice and public policy.

This book brings an unusual opportunity to explore the peculiarities of America's health care industry's approach to fraud control, when compared with the financial services sector, credit card companies, or the Internal Revenue Service—all of which have to defend themselves against fraud.