I think you misunderstand the list. I was in charge of the group that investigated providers for fraud and if you were caught, they would prosecute you and you would be precluded from the Medicare program.

But when I worked for Medicare, we conducted a CMS special study of all physicians. We had access to an entire physicians "billing" history (including private insurance data, Medicare and Medicaid, and military patients) and algorithms that used patient risk adjusted data to compare physician expected costs and outcomes with their peers at the local, regional, and national level.

Note: this analysis was based on their practice patterns over a year to avoid a single patient's treatments from skewing the results. The focus was not on how they treated a single patient, but their practice patterns and the outcomes and costs those patterns produced.

Unrelated to the physician's claims data was the patient's claims data that helped determine the patient's underlying health conditions based on treatments they were receiving from other providers.

patients".

From that data we met with physicians and other providers, that were outliers to show them their data and how much outside the standard of care they were and how it impacted the outcomes and cost of care they delivered.

The results showed some physicians were practicing outside the standard of care due to ignorance of the changes that had occurred over time, they were generally appreciative of our efforts and quickly conformed to the new standards of care (developed by their professional societies). I don't consider this group "bad", since they were making honest mistakes.

Both others were clearly being influenced by the ability to overutilize services to maximize income. And others simply had a greater risk of a bad outcome due to sloppy practices that produced higher infection rates and other post treatment issues. The same was true of facilities, where we measured variations in infection rates down to the hospital unit level, lengths of stay, and a host of other factors. Bad outcomes tend to be very expensive. Excess utilization is very expensive. Physicians and facilities that routinely produce bad outcomes do not make the Medicare precluded list. Nor do physicians and facilities that routinely generate higher cost of care as long as they are not acting fraudulently.

However, as a private insurer, I don't want them in my network. In fact, some private insurers began to sell the fact that they send employees to medical facilities with outcomes in the top 10% (centers of excellence) for treatment, which is something Medicare cannot do.

I appreciate what you are saying, but having had the unique ability of running 400+ physician groups and being an executive for private health insurance and government health insurance programs during my career, your response is based on what "you can see". You don't really know how much "big brother" knows about your practice. As an aside, what I hated about Medicare's approach was rather than simply narrow their network to providers with good outcomes, they kept passing expensive regulations that providers had to conform to, when a minority of "bad apples" were creating all the problems.

When I ran a benefit management company, we developed the "invisible fence". If as a physician your outcomes and costs were within the standard of care, you were not required to do any preauthorization or referral requests saving you and our clients' money and speeding up the process of delivering good care. But if you were outside the standards, you were required to request referrals and secure a preauthorization for those "cases" where your practice pattern and outcomes were outside the standard of care.

We also provided a face-to-face meeting with our medical director to go through why you were being required to follow the referral/preauthorization process. If your practice continued to be an outlier, we simply did not renew your contract.