J Eval Clin Pract. 2025 Aug;31(5):e70217. doi: 10.1111/jep.70217.
ABSTRACT
IMPORTANCE: Identifying how fraudulent practices affect quality performance metrics is crucial for enhancing healthcare delivery and maintaining the integrity of the Medicare system.
OBJECTIVE: To examine the association between fraud and abuse perpetrator providers (FAPs) and their performance on quality metrics within the Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA).
DESIGN: A retrospective observational study using exact matching and propensity score matching to balance comparison groups.
SETTING: Analysis of Medicare Quality Payment Program (QPP) data from 2017 to 2021.
PARTICIPANTS: A total of 12,364 physician-year observations, including 1300 provider-year level FAPs identified between 2020 and 2023 and 11,064 matched non-FAPs.
EXPOSURES: Provider status as fraud and abuse perpetrators based on inclusion in the List of Excluded Individuals and Entities from the Office of Inspector General.
MAIN OUTCOMES AND MEASURES: MIPS scores across key categories: Final score, Quality score, Promoting Interoperability (PI) score, Improvement Activities (IA) score, and Cost score.
RESULTS: FAPs scored significantly lower than non-FAPs in Final score, Quality score, PI score, and IA score (all p < 0.05). The negative impact of FAP status was more pronounced among individual practitioners, while FAPs participating in Advanced Alternative Payment Models exhibited higher scores on certain metrics. No significant differences were observed in Cost scores between FAPs and non-FAPs.
CONCLUSIONS AND RELEVANCE: Fraudulent practices are associated with lower performance on quality-related metrics under MACRA’s MIPS framework, particularly among individual practitioners. While lower quality scores align with expectations for providers committing fraud, the absence of significant differences in Cost scores highlights potential shortcomings in the MIPS scoring system, suggesting that cost metrics may not be sufficiently sensitive to fraudulent practices. These findings underscore the need for continuous refinement of both quality and cost measures to enhance the integrity and effectiveness of healthcare delivery.
PMID:40700659 | DOI:10.1111/jep.70217
