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Expanding Physician Education in Health Care Fraud and Program Integrity

Agrawal, Shantanu MD, MPhil; Tarzy, Bruce MD; Hunt, Lauren MPH; Taitsman, Julie MD, JD; Budetti, Peter MD, JD

Academic Medicine:
doi: 10.1097/ACM.0b013e318299f5cf
Articles
Abstract

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in thehealth care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians’ lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.

In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. They recommend that various stakeholder organizations take part in the development and implementationprocess to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.

Author Information

Dr. Agrawal is medical director and director of data sharing and partnership, Center for Program Integrity, Centers for Medicare & Medicaid Services, Baltimore, Maryland.

Dr. Tarzy is lead medical consultant, Medical Review Branch, California Department of Health Care Services, Sacramento, California.

Ms. Hunt is health insurance specialist, Center for Program Integrity, Centers for Medicare & Medicaid Services, Baltimore, Maryland.

Dr. Taitsman is chief medical officer, Office of the Inspector General, Department of Health and Human Services, Washington, DC.

Dr. Budetti is deputy administrator for program integrity and director, Center for Program Integrity, Centers for Medicare & Medicaid Services, Washington, DC.

Editor’s Note: A commentary by M.A. Lyles appears on page 1061.

Correspondence should be addressed to Dr. Agrawal, CMS Center for Program Integrity, 7500 Security Blvd., Mail Stop AR-18-50, Baltimore, MD 21244; telephone: (410) 786-1795; fax: (410) 786-0604; e-mail: shantanu.agrawal@cms.hhs.gov.

© 2013 by the Association of American Medical Colleges