correction

An earlier version of this article suggested that Yelp flagged 40 potentially fake reviews after being contacted by The Washington Post. Yelp said its software had identified those reviews earlier and took the step of “unrecommending” them, which makes them less visible and prevents them from counting toward a business’s overall rating. The article has been corrected.

Patricia Limbaugh was desperate to find care for her husband, whose drinking had spiraled out of control after the death of one brother by suicide, another from a heart attack, and a lot of stress at work. They had tried a rehabilitation program recommended by a hospital near their home just outside Nashville, but neither of them was happy because the facility refused to let them communicate. “That’s when I started Googling alcohol treatment centers,” said Limbaugh, “cause I thought I’ve got to get him out of this place and get him somewhere else.”

Limbaugh’s search in the early spring of 2019 brought her to an addiction treatment facility called The Center, A Place of Hope in Edmonds, Wash. The facility had glowing reviews on Google like this one from a Jeremy Maria: “I don’t know if I have words enough to truly express my gratitude to each and every member of my team.” Another review by Devin Lindsey cited specific staff members: “I’ve had lightbulb moments with Justin Hartfield, Lisa Chinn, and Lynsey Isaacs and all have been helpful in my improvement of self-worth, skills and tools to take with me.”

Limbaugh and her husband flew to Washington state, and he checked in on April 11, 2019. But after he got home from the 30-day treatment regime, her husband confessed he drank while he was there. “The housing was off-site from the facility,” Limbaugh said. At the end of each day, she said, “he would go and have a nice meal, a couple of glasses of wine and, or he’d get a bottle. And so, he drank the whole time he was there.”

The Washington Post asked The Center about each of Limbaugh’s claims. In an email, Tom Lether, an attorney for The Center, would not respond specifically to her charges, saying only: “The Center strongly disagrees with these allegations.”

Limbaugh said she felt taken in by the reviews. “I felt deceived,” she said.

It turns out that the reviews she relied on from Maria and Lindsey — and dozens of others on The Center’s site — were fake, according to separate analyses conducted by Google and the review site Trustpilot after they were approached by The Post.

Fake Review Watch, a consumer watchdog site founded by former fraud investigator Kay Dean, had initially discovered the fake reviews and shared them with The Post. The Post then shared the reviews with Google and Trustpilot.

Although Limbaugh thought she could trust the reviews on a health-care provider’s site, she had stumbled upon a problem created by a convergence of forces: a public that has come to rely on consumer reviews for almost everything including medical care; a robust industry of global review fraud; competition among physicians; large Internet companies with minimal incentive to weed out that fraud; scattershot disciplinary actions by professional medical bodies; and lax enforcement by government agencies.

When asked about potentially fraudulent activity on The Center, a Place of Hope’s Google page, Google took down 93 reviews, including the ones by Maria and Lindsey.

Google’s algorithms and staff use indicators such as the location of the reviewer to assess whether a posting is from a real patient. Ben Jose, a Google spokesman, said the company “removed reviews that were found to be in violation of our policies.” The Center still has a 4.5-star rating, and Google did not put up a notice that it had taken down suspicious postings.

The Post also contacted the review sites Yelp and Trustpilot about potentially fake reviews of The Center. Yelp said its automated processes had previously “unrecommended” 40 reviews, which makes them less visible and prevents them from counting toward The Center’s overall rating. Trustpilot took down 73 posts it determined were fraudulent — about half of The Center’s reviews at the time.

Wahid Lodin, a spokesman for Trustpilot, said the company weeds out fraud through “tracing IP addresses, researching a user’s post cadence, analyzing the word usage in their review.” Trustpilot put an alert on The Center’s page, saying that it had detected “a number of fake reviews for this company.”

Fake Review Watch’s Dean said she has found dozens of Facebook groups where businesses including medical practices buy and sell fake reviews. Inside one of these groups, the watchdog said it found a Bangladeshi review broker who recruited people to write fake positive reviews for The Center.

In a video, Fake Review Watch documented what it said was an exchange in which the broker gave the paid recruits the exact text that would later appear as reviews written by Maria and Lindsey. At least two of the employees mentioned in Lindsey’s review appeared to have a connection with The Center. One listed The Center on a LinkedIn page, another used the center’s telephone number and address on a health site.

The Post cannot confirm who paid to put the fake positive reviews on The Center’s site.

Lether said The Center and the facility’s founder, Gregory Jantz, never paid anyone to write fake reviews and took measures to ensure that reviews were accurate.

“Dr. Jantz indicates the Center has been investigating malicious online attacks through spamming, bot attacks, obvious fake reviews and social media manipulation,” Leather wrote in an email.

“The Center receives numerous testimonials and postings. The Center exercises due diligence to make sure that postings or online information is correct and accurate. To the extent The Center identifies any inaccurate postings or information, the Center will remove The Post immediately.”

Google did not respond when asked if The Center has tried to get fake reviews taken down. Trustpilot says it never heard from anyone at the facility that there might be fraud on its page. “We never heard from them regarding that,” Lodin said.

Dean said she has identified fake reviews for dozens of other medical practices including two separate practices in California, a rheumatologist and a pain clinic, both involving the same review broker as The Center.

Posting fraudulent reviews may be illegal under federal and state laws if there is financial gain involved. But enforcement is scattershot, and it is hard to find cases of disciplinary action from professional bodies for review fraud. Records from the Medical Board of California, the state with the largest number of practicing physicians, show no actions taken against doctors over the past four years for fake reviews.

“When the board receives a complaint against a physician or allied health-care professional it oversees, the complaint is investigated,” board spokesman Carlos Villatoro said. The board does not discuss ongoing investigations.

New York state has the second-highest number of practicing physicians, and neither the Office of the New York State Attorney General nor the Office of Professional Medical Conduct could cite a case that had been brought against an individual medical doctor for manufacturing fraudulent reviews.

The New York attorney general’s office did point to a case against an urgent care center that purchased fake reviews, but there was no indication that individual doctors were involved. Medrite Urgent Care faced a $100,000 fine and agreed to measures to increase the honesty and transparency of its reviews.

Michael Atleson, an attorney at the Federal Trade Commission, could not recall an instance over the past two decades where the agency filed an action against an individual physician for fake online reviews. But he cautioned that “the FTC does not confirm nor deny the existence of investigations or comment on investigations, even if they have been publicly disclosed.”

Although there is no easy way to quantify how many physicians and health-care providers are faking reviews, Curtis Boyd, the CEO and founder of Objection Co., which specializes in identifying fake local business reviews for business owners, estimated that as many as 20 percent of businesses in the health-care industry including doctors have suspicious review activity on Google and Yelp.

Boyd said he based his estimate on work he did for sites like Upwork, Fiverr and Amazon’s Mechanical Turk, where freelancers look for work. There, he said, he found a shady marketplace of brokers looking to hire people to write positive reviews for their customers — including medical doctors. Boyd said he persuaded 35 of those brokers to sell him their client list, which he used to train his algorithms to identify fake reviews.

Using artificial intelligence, Boyd was able to detect details that were likely to signify that a review was fake. “Exclamation points was one of the most obvious ones, like excessive use of exclamation points,” he said. “We also saw a lot of sentiment, over-the-top sentiment like the word ‘love.’ And it was kind of interesting to see over-the-top sentiment. We think that it has to do with, like, a compensation of a lack of actual experience.”

He said certain types of physicians were more likely to have fake reviews. “Physicians with their own personal private practices tend to have more suspicious reviews,” he said, “versus physicians who might be an employee of a large medical center or a hospital.”

Marni Jameson Carey, executive director of the Association of Independent Doctors (AID), a national nonprofit trade group for physicians in private practice, condemns physicians who post fake reviews. However, Carey said that she can imagine how some independent medical doctors might feel desperate to boost their online reputation to compete against large hospitals that are buying up independent medical practices.

“Employed physicians have entire marketing departments behind them,” she said. “It is certainly hard to survive as an independent. There’s a sense of guerrilla warfare out there.” Carey said the association has not caught any physicians posting fake reviews. “If we ever do encounter this issue, we will have to decide how to confront it and the physician at that time,” she said.

In a statement, American Medical Association President Susan R. Bailey said that “the credibility of some rating sites is questionable.” Bailey suggests “online opinions and reviews of physicians should be taken with a grain of salt and should certainly not be a patient’s sole or primary source of information when looking for a physician.”

However, patients are increasingly using review sites to find doctors, according to a study by Software Advice, a consulting firm. According to a 2020 survey, over 70 percent of patients use online reviews as the first step to finding a new doctor. That’s up from a similar survey in 2013 that found that only 25 percent of patients used online reviews to find a physician.

In our review-crazed age, patients appear more likely to trust user review sites such as Yelp and Google over government sites about physicians, according to a 2018 study by the Brookings Institution, which looked at how patients choose health-care providers. The study’s participants repeatedly favored a physician’s five-star rating on Yelp over a one- or two-star rating from the government.

“The reason that physicians are paying for these fake reviews is that they know the importance of how it will drive patients to their office,” said Niam Yaraghi, an assistant professor of business technology at Miami Herbert School of Business at the University of Miami who conducted the study.

Sites like Zocdoc, which charge physicians for appointment bookings, allow only patients who have booked appointments with a doctor to leave reviews. However, Laura C. Mikulski, vice president of business development and physician relations at Physician Referral Marketing, said patients may be reluctant to leave bad reviews for fear of exposing themselves to a lawsuit from their provider. “If I am a patient,” Mikulski said, “and I have a negative experience with my physician, I don’t want my physician to try to sue me or to try to terminate services.”

Jessica Aptman, a spokeswoman for Zocdoc, said that “although providers are our paying customers, our company’s number one core value is Patients First, and our mission is to give power to the patients.” Zocdoc also allows anonymous reviews, though the company does have records of who the reviewers are.

Many physicians would prefer to be taken off all of these review sites. Physicians Working Together organized a Change.org petition to remove medical doctors from Yelp. Founder Kimberly Jackson, who practices family medicine in Phenix City, Ala., said that medical doctors find themselves in a bind. If a patient writes a negative review, a doctor can’t give a full-throated defense because of HIPAA privacy regulations. “You’re not supposed to be sharing patients’ confidential health information,” Jackson said. “In a lot of cases, we don’t even want to acknowledge that you’re a patient.”

In addition, Jackson argues that patients aren’t always the best judge of quality medical care. “Sometimes people have their own agendas,” she said. “I’ve experienced that myself, there was a Google review, or a person said that, you know, the office is horrible. The receptionist was so rude, and I never made an appointment with this doctor. But they still went ahead and reviewed, like, my bedside manner and my medical knowledge and whatever.”

A study late last year in the peer-reviewed quarterly journal Information Systems Research underscores her point. It tracked 10 years of data from Northern Texas hospital patients struggling with chronic diseases. They compared outcomes for these patients with the reviews given to the doctors they saw. The study measured factors such as readmission risk and other broadly accepted measures of clinical outcomes. It found star ratings and written reviews equally bad at judging the quality of medical care.

Another study, in the Journal of the American Board of Family Medicine in 2018, found that patients gave doctors who overprescribed opioids higher ratings.

Some people may think they can tell which reviews are real and which are fake. But “humans are notoriously terrible at determining whether a review is fake,” said Zachary Pardes, director of brand advertising and communications for North America at Trustpilot. He said many people wrongly think they can spot a fake review by looking for grammatical errors and poor syntax or through a profile picture. But the algorithms used by his company to find fakes are also imperfect, he admits.

“I think it is a volume, it’s a scale problem," he said. "We are in this constant game of cat and mouse.”

Google, which is quickly becoming the biggest player when it comes to consumer reviews, said it is getting millions of new postings a day. Although Google might not catch all the fakery, Jose, the Google spokesman, says, “We continually invest to improve our automated systems to better detect fake reviews while also deploying analysts who investigate suspicious content around-the-clock.”

But when dealing with hundreds of millions of reviews, even a fraction of missed fraud can have a significant effect, said Mike Blumenthal, co-founder of Nearmedia, a research company that focuses on local businesses and the Internet. “The problem with artificial intelligence, machine learning, is that it’s a statistical approach,” he said.

Blumenthal argues that the companies don’t have sufficient incentive to catch it all. “To capture the rest would require human curation," he said. "They’re not willing to spend the money it would take to more effectively manage that part of the fake reviews they miss with their algorithms.”

Blumenthal also points out that platforms face no penalties when they do miss fraud. Federal law protects these companies from liability. Under Section 230 of the Communications Decency Act, Google, Yelp, Trustpilot and other platforms are generally insulated from legal liability for fraudulent content posted by third parties on their sites.

When asked about Blumenthal’s criticism, Google directed The Post to prepared remarks by its CEO, Sundar Pichai, at a congressional committee hearing in March about misinformation and extremism on tech platforms, defending Section 230. “Without Section 230, platforms would either over-filter content or not be able to filter content at all.”

Blumenthal finds the fake reviews on medical websites especially troubling. “When it comes to a restaurant, the worst that can happen is you will get a bad meal," he said. "But with a physician, the stakes of bad medical care can be higher.”

And in the absence of reliable and easily accessible information about doctor performance, most patients are going to continue to resort to online reviews, Yaraghi, the Miami professor, said.

“Patients are not well-informed about this, and they are unfortunately taking these reviews more seriously than they should,” he said. “The reason these online reviews are becoming more important is because there is a vacuum.”