TY - JOUR
T1 - Impact of Enforcement on Healthcare Billing Fraud
T2 - Evidence from the USA
AU - Flasher, Renee
AU - Lamboy-Ruiz, Melvin A.
N1 - Funding Information:
We gratefully acknowledge helpful comments and suggestions from reviewers and participants at 2015 American Accounting Association Midwest Region Meeting and the 2016 American Accounting Association Forensic Accounting Research Conference. We acknowledge the contribution of Jason Stanfield for his comments and suggestions for the paper.
Publisher Copyright:
© 2017, Springer Science+Business Media B.V.
PY - 2019/6/20
Y1 - 2019/6/20
N2 - Each state’s Medicaid Fraud Control Unit (MFCU) prosecutes billing fraud cases against individual healthcare providers who fraudulently bill Medicaid for services provided. Once an individual is convicted of billing fraud, the Office of Inspector General for the Department of Health and Human Services may exclude the individual from billing any federal government healthcare program, including Medicaid. Excluded individuals are added to a public list of exclusions, which restricts their ability to practice professionally. Prompted by criminology research into the impact of policing resources, we test whether these government enforcement initiatives against fraud serve as a deterrent to would-be fraudulent billers. We document that key enforcement proxies, the staffing level and budget of an MFCU, are positively associated with the yearly number of exclusions added at the state level. Our results are consistent with the exclusion list not being a deterrent but provide support for MFCUs’ fraud detection efforts. This paper provides industry-specific fraud insights for auditors and other individuals involved in public policy, specifically Medicaid, and introduces a novel dataset to the accounting fraud research literature.
AB - Each state’s Medicaid Fraud Control Unit (MFCU) prosecutes billing fraud cases against individual healthcare providers who fraudulently bill Medicaid for services provided. Once an individual is convicted of billing fraud, the Office of Inspector General for the Department of Health and Human Services may exclude the individual from billing any federal government healthcare program, including Medicaid. Excluded individuals are added to a public list of exclusions, which restricts their ability to practice professionally. Prompted by criminology research into the impact of policing resources, we test whether these government enforcement initiatives against fraud serve as a deterrent to would-be fraudulent billers. We document that key enforcement proxies, the staffing level and budget of an MFCU, are positively associated with the yearly number of exclusions added at the state level. Our results are consistent with the exclusion list not being a deterrent but provide support for MFCUs’ fraud detection efforts. This paper provides industry-specific fraud insights for auditors and other individuals involved in public policy, specifically Medicaid, and introduces a novel dataset to the accounting fraud research literature.
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U2 - 10.1007/s10551-017-3650-z
DO - 10.1007/s10551-017-3650-z
M3 - Article
AN - SCOPUS:85026922809
VL - 157
SP - 217
EP - 229
JO - Journal of Business Ethics
JF - Journal of Business Ethics
SN - 0167-4544
IS - 1
ER -