Exclusions: An Exploratory Analysis of Felony Fraud

• In Event: Fraud Risk, Tax Avoidance, and Felony Fraud

Abstract

This study examines the environment within which healthcare fraud, including billing fraud, is prosecuted in the United States. The Office of Inspector General for the Department of Health and Human Services publishes exclusions data detailing healthcare providers, individuals, who cannot bill federal government health programs to obtain revenue. We provide evidence supporting an association between healthcare provider type and fraud. We further document a positive correlation between the state level enforcement environment and the number of individuals for each state on the exclusions list. When assess the audit risks related to healthcare frauds, it is important to consider that the fraud convictions underrepresent the prevalence of the frauds as fraud convictions are associated with healthcare provider type and are associated with a regional prosecution environment.

Authors

• Renee Flasher, Ball State University

• Melvin Arnaldo Lamboy Ruiz, Iowa State University