IRVINE : UCI Trio Publishes Medical-Fraud Study

The Newport Beach psychiatrist had been caught billing the state Medi-Cal program for “therapy” sessions that, in fact, were sexual liaisons with a patient.

But when UC Irvine criminologist Paul Jesilow asked the doctor if he felt any remorse, he said no.

“He said he had to bill the government,” Jesilow recounted. Since the psychiatrist’s wife did his bookkeeping, she would have been suspicious if he had not.

Over the past 10 years, Jesilow and UCI colleagues Henry Pontell and Gilbert Geis have explored “the subculture of medical delinquency,” studying white-collar crimes, such as double billing, and interviewing 42 New York and California doctors who were punished for fraud.

Not one of those doctors felt remorse for the white-collar crimes, Jesilow and his colleagues reported in this week’s Journal of the American Medical Assn.

Rather, the UCI criminologists said, the physicians described themselves as occasionally “a little careless” but mostly “victims” of a government health program that didn’t pay enough.

“Overcharging for services and ordering excessive tests was seen as necessary to ‘make back’ what ‘reasonably’ should have been paid them,” the UCI researchers said.

Ironically, when the UCI researchers interviewed a sample of 40 California doctors who were thought to be “honest” and who had never been accused of Medi-Cal fraud, 20% of those with large Medi-Cal practices said they too occasionally cheated the government. They said they couldn’t “make a living” from Medi-Cal if they didn’t, Jesilow said.

The authors concluded that there was a “subculture of medical delinquency”--not unlike the “subculture of juvenile delinquency”--that sanctions Medicaid fraud.

But there are strong signals that “the medical profession does want to clean up its act,” Jesilow said. In 1981, when he began his research, the American Medical Assn. “paid little attention” to medical fraud, he said.

“They didn’t think they should bother with it. But in the last five years, they’ve done a slow turnaround,” Jesilow said. “They recognize they have a situation that is intolerable and that affects the profession’s prestige . . . that if (some) doctors cheat, the public will assume all doctors cheat. The AMA now is supportive of efforts to create accountability.”