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Policing Physicians - Practitioner Fraud and Abuse in a Government Medical Program

NCJ Number
Social Problems Volume: 30 Issue: 1 Dated: (October 1982) Pages: 117-125
Date Published
9 pages
Interviews with officials of California's Medi-Cal program focus on fraud and abuse by physicians participating in government medical programs.
Researchers found that the program's very organization invites fraud since the fee-for-service delivery system in California offers physicians a chance to amass considerable wealth with little risk of detection and conviction. Diagnostic tests that have not been performed can be easily billed to the State as can a variety of other spurious costs. Also, the physician's professional background affords strong protections against discovery, and if discovery does occur, physicians have an array of tactics to guard against sanctions. Authorities charged with policing the Medi-Cal program exhibit a number of behaviors tied to the program structure. They must balance their charge to maintain the program's integrity with the practical goal of keeping their powerful constituents, medical societies, at bay by not moving forcefully against too many physicians. Nor can they adopt tough investigative strategies that physicians might regard as a violation of personal autonomy; physicians would merely refuse to participate in the Medi-Cal program. Moreover, the evidence needed to prove the element of criminal intent, essential for criminal action, is extraordinarily hard to prove beyond a reasonable doubt. Suspending a doctor from the Medi-Cal program for abuse usually takes 3 to 4 years, and officials have to be certain cases are airtight. Thus, only the most flagrant abuses are prosecuted, and program administrators emphasize actions that can be taken without initiating formal legal proceedings.

Date Published: January 1, 1982