Abstract
The present problem of policing healthcare was delineated three-quarters of the way through the 20th century. On the one hand, were the billions of dollars of healthcare needs of a burgeoning population that was supplied by an extensive array of providers. On the other hand, were a small group of individuals mandated to insure that monies were spent on legitimate healthcare expenses. A form of “tightrope enforcement” was practiced by the control agents in response to this situation; they had to show wrongdoing without offending the healthcare industry as a whole, or at least too many of its members.1 At the time, the problem manifested itself as a conflict between government agents and physicians. Henry Pontell and his colleagues commented on the matter with respect to California’s Medicaid program for the indigent:
Government control units need the cooperation of medical societies to inform physicians about program policies and guidelines and to help insure that regulations are taken seriously. Officials believe that if they “go too far” in regulating physicians in the program, they are likely to forfeit the support of medical societies, and that this would result in a lowered rate of participation by physicians in the Medi-Cal program. This in turn would further restrict the sources of healthcare for the population served by Medi-Cal. It could also raise costs, since patients would likely go for care to more expensive facilities, such as the emergency department of hospitals, if a Medi-Cal physician was not available. Control agents, as a response to the dilemma, only pursued cases that involved blatant wrongdoing, and where evidence was unequivocal.2
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Active Project Report (2004) “Facts About the Centers for Medicare and Medicaid Services.” Centers for Medicare and Medicaid Services, http://www.cms.hhs.gov/ researchers/p ro j ects/APR /2004/facts.pdf
American Medical Association (2003) “States in Crisis: 19 States Now in Full-blown Medical Liability Crisis.” AM A News Release (6 Oct).
Beck, Rachel (2005) “Ignorance Still a Viable Defense.” Charlotte Observer 6D (July 3).
Black, Bernard et al. (2005) Stability, Not Crisis: Medical Malpractice Claim Out-comes in Texas, 1988-2002. (draft March) Columbia Law School, Law and Economics Working Paper No. 270, University of Illinois, Law and Economics Research Paper No. LE05-002, University of Texas Law School, Law and Economics Working Paper No. 30. Social Science Research Network electronic library at http://papers.ssrn.com/abstract= 678601.
Bovbjerg Randall R., and Kenneth Petronis (1994) “The Relationship Between Physicians’ Malpractice Claims History and Later Claims. Does the Past Predict the Future?” Journal of the American Medical Association 272(18): 1421–6 (9 Nov).
Broad, William, and Nicholas Wade (1982) Betrayers of the Truth. New York: Simon and Schuster.
Brown, June G. (1994) A Compendium of Reports and Literature on Coding of Physician Services (OEI-03-91-00921). Washington, DC: Inspector General, Department of Health and Human Services.
Brown, June G. (1999) Interoffice Memorandum, to: Nancy-Ann Min DeParle, Administrator, Health Care Financing Administration. SUBJECT: monitoring the accuracy of hospital coding (OEI-01-98-00420) (January 21). http://oig.hhs.gov/oei/reports/ oei019800420.pdf#search=’NancyAnn%20Min%20DeParle%20%20January%2021 %2C%201999%2C%20%20SUBJECT%3A%20monitoring%20the%20accuracy% 20of%20hospital%20coding%20%28OEI019800420%29’
Cane, Peter (1982) “Justice and J ustifications for Tort L lability.” Oxford Journal of Legal Studies 2(l):30–62 (Spring).
Cohen, Thomas H. (2005) “Civil Justice Survey of State Courts, 2001. Punitive Damage Awards in Large Counties, 2001.“ U.S. Department of Justice/Office of Justice Programs. Bureau of Justice Statistics, NCJ 208445 (March).
Cone, Jonathan et al. (2003) “Health Care Fraud.” American Criminal Law Review 40:713.
Danzon, Patricia M. (1994) “The Swedish Patient Compensation System: Myths and Realities.” International Review of Law and Economics 14:453–466.
Department of Justice (1999) “Health Care Fraud Report: Fiscal Year 1998.” Washington, DC (5 Aug), http://www.usdoj.gov/dag/pubdoc/health98.htm.
Eldenburg, Leslie, and Sanjay Kallapur (1997) “Changes in Hospital Service Mix and Cost Allocations in Response to Changes in Medicare Reimbursement Schemes.” 23 Journal of Accounting and Economics 31–51.
Eldenburg, Leslie, and Sanjay Kallapur (2000) “The Effects of Changes in Cost Allocations on the Assessment of Cost Containment Regulation in Hospitals.” 19 Journal of Accounting and Public Policy 97–112.
Gardiner, John A., and Theodore R. Lyman (1984) The Fraud Control Game: State Responses to Fraud and Abuse in AFDC and Medicaid Programs. Bloomington: Indiana University Press.
Geis, Gilbert (1975) “Victimization Patterns in White-Collar Crime.” in I. Drapkin and E. Viano, eds., Victimology: A New Focus. Exploiter and Exploited, vol 5. Lexington, Mass.: DC Heath.
General Accounting Office (1966) Health Care Fraud. Information-Sharing Proposals to Improve Enforcement Efforts. GAO/GGD-96-101 (May).
General Accounting Office (1992) “Health Insurance: Vulnerable Payers Lose Billions to Fraud and Abuse.” in U.S. House of Representatives, Committee on Government Operations, Subcommittee on Human Resources and Intergovernmental Relations (May). Washington, DC: Government Printing Office.
Granelli, James S. (2005) “Laws to Curb Suits May Have Missed the Mark.” Los Angeles Times. (3 June). http://www.latimes.com/news/printedition/asectionAafitort 3jun03,l,7612887.story?page=l&coll=la news a_section.
Guterman, Stuart, and Allen Dobson (1986) “Impact of the Medicare Prospective Payment System for Hospitals.” Health Care Financing Review 7:97–115.
Harmon, Robert G. (1990) “The National Practitioners Data Bank.” Journal of the American Medical Association 264:945.
Harrington, Kirsten B. (2003) Clamping down on Upcoding: Government Efforts to Curb a Medicare Billing Fraud and Abuse. Unpublished paper, The University of Nebraska, Lincoln.
Holmes Jr., Oliver W. (2005/1881) The Common Law. New Brunswick: Transaction Publishers.
Holmes, Jr., Oliver W. (1873) “The Theory of Torts.” A. L. Rev. v. 652 7:660.
Institute of Medicine (2000) To Err Is Human: Building a Safer Health System.
Jesilow, Paul et al. (1985) “Medical Criminals: Physicians and White-Collar Offenses.” Justice Quarterly 2:149–166 (June).
Jesilow, Paul et al. (1993) Prescription for Profit: How Doctors Defraud Medicaid. Berkeley: University of California Press.
Jesilow, Paul et al. (1995) “Doomed To Repeat Our Errors: Fraud in Emerging Health Care Systems.” Social Justice 22(2)125–138.
Jesilow, Paul (2005) “The Effects of Fraud on the Evaluation of Health Care.” Health Care Analysis: An International Journal of Health Care Philosophy and Policy 13:239–245.
Kinney, Eleanor D. (1996) “Malpractice Reform in the 1990s: Past Disappointments, Future Success?” Journal of Health Politics, Policy and Law 21:1 (Spring).
Klein Donald F. (1991) “Scientific Fraud and Misconduct.” Journal of Clinical Psychopharmacology ll(6):337–9.
Lavenant, Claudia E. et al. (2002) “Tort Reform and Physician Sanctioning.” 24 Law and Policy 1–16.
Maltin, Vanessa (2004) “Fraud Plagues U.S. Health Care.” The Atlanta Journal-Constitution Dl (14 July).
Jet Magazine (1997) “Manhattan, NY, Doctor Slain.” http://www.findarticles.eom/p/ articles/mi_ml355As_n26_v93/ai_20028174. (17 Nov).
McCormack, Patricia (1979) “Once Hospital Board Insider: Carter Reveals Taking Part in Medical ‘Ripping Off.’” Los Angeles Times (25 Apr.).
Mitchell, Colby L. et al. (2003) “Billing for Inpatient Hospital Care.” American Journal of Health-System Pharmacists 60:S8–S11.
Moses, Jennifer (2003) “False Claims.” American Criminal Law Review 40:495.
Pear, Robert (2005) “F.B.I. Said to Misuse Funds for Health Fraud Cases.” New York Times (16 May) http://www.nytimes.com/2005/05/16/politics/16fraud.html?
Pollock Alan V., and Michael Evans (1985) ”Bias and Fraud in Medical Research: A Review.” Journal of the Royal Society of Medicine 78:937–940.
Pontell, Henry N. et al. (1982) “Policing Physicians: Practitioner Fraud and Abuse in a Government Medical Program.” Social Problems 117–125 (30 Oct).
The Deseret News: Salt Lake City (2005) “Prosecutors Aren’t Finished with Health-South.” (4 July) p. 1.
Prospective Payment Assessment Commission (1992) Medicare and the American Health Care System: Report to Congress. Chicago, IL: Commerce Clearing House.
Psaty, Bruce M. et al. (1999) “The Potential Costs of Upcoding for Heart Failure in the United States.” The American Journal of Cardiology 84:108–109.
Richardson, Sally K. (1994) “Health Care Reform in the United States.” Paper presented at Annual Conference of the National Association of Surveillance and Utilization Review Officials. Seattle, Washington.
Rosenberg, David (1995) The Hidden Holmes: His Theory of Torts in History. Cambridge: Harvard University Press.
Ross, Edward A. (1907) The Criminaloid. Atlantic Monthly 99:44–50 (January).
Schwartz, William B., and Neil Komesar (1978) “Doctors, Damages and Deterrence. An Economic View of Medical Malpractice.” New England Journal of Medicine 298(23): 1282–9.
“Setback in Birmingham After…” The Washington Post F2. (3 July).
Soderstrom, Naomi S. (1990) “Are Reporting Errors under PPS Random or Systematic?” Inquiry Blue Cross and Blue Shield Association 27:234–241.
Sparrow, Malcolm K. (2000) License to Steal: How Fraud Bleeds America’s Health Care System. Boulder: Westview Press.
Starr, Paul (1982) The Social Transformation of Medicine. New York: Basic Books.
Sutherland, Edwin H. (1945) “Is ‘White Collar Crime’ Crime?” American Sociological Review 10:260–271.
Thorpe, Kenneth E. (2004) “The Medical Malpractice ‘Crisis’: Recent Trends And The Impact Of State Tort Reforms.” Health Affairs W20–W30 (January).
Traska, Maria (1990) “Unbundling Could Be Costing You a Bundle.” Business and Health 20–27 (March).
U.S. Department of Health and Human Services and U.S. Department of Justice (2002) Health Care Fraud and Abuse Control Program Annual Report for FY 2001. http://oig.hhs.gov/reading/hcfac/HCFAC%20Annual%20Report%20FY%202001.htm
United States Files Suit Against Tenet Healthcare Alleging False Claims Billing to Medicare (2003) (9 Jan) http://www.usdoj.gov./opa/pr/2003/January/03_civ_007.htm.
United States General Accounting Office (2001) “DOJ Has Improved Oversight of False Claims Act Guidance.” Report to Congressional Committees (March).
Vidmar, Neil et al. (2005) Uncovering the “Invisible” Profile of Medical Malpractice Litigation: Insights from Florida. 54 De Paul Law Review 315–354.
White, Edward G (1977) “White: The Intellectual Origins of Torts in America.” The Yale Law Journal 86:671–693.
Zuckerman, Stephen et al. (1990) “Effects of Tort Reforms and Other Factors on Medical Malpractice Insurance Premiums.” Inquiry 27:167, 182.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2007 Springer Science+Business Media, LLC
About this chapter
Cite this chapter
Jesilow, P. (2007). Policing Healthcare at the Dawn of the New Millennium. In: Pontell, H.N., Geis, G. (eds) International Handbook of White-Collar and Corporate Crime. Springer, Boston, MA. https://doi.org/10.1007/978-0-387-34111-8_29
Download citation
DOI: https://doi.org/10.1007/978-0-387-34111-8_29
Publisher Name: Springer, Boston, MA
Print ISBN: 978-0-387-34110-1
Online ISBN: 978-0-387-34111-8
eBook Packages: Humanities, Social Sciences and LawSocial Sciences (R0)