‘An unnavigable mess’: GPs ill-equipped to manage Medicare compliance, research finds

Anastasia Tsirtsakis

24/01/2022 4:06:15 PM

The first qualitative study to examine practitioners’ billing experiences in Australia points to the need for urgent structural reforms.

A stressed female doctor.
GPs say there is a lack of training and education, as well as an absence of reliable advice and support, around medical billing – even from Medicare.

Medicare compliance is a persistent issue for GPs and other clinicians in Australia.
Errors can have consequences for healthcare providers, patients and taxpayers, with up to 15% of the Medicare Benefits Schedule’s (MBS) total costs estimated to be a result of non-compliant billing.
But new research has added to a growing body of evidence that suggests it is not doctors deliberately abusing the system, but rather clinicians struggling to understand what can be a complex system, with highly interpretive billing rules.
Published in PLOS ONE, researchers from UTS, UNSW and Southern Cross University conducted in-depth interviews with 27 GPs and non-GP specialists across NSW who claim Medicare reimbursements in their daily practice and identified five key issues:

  • Little or no induction or training around medical billing
  • Lack of knowledge and understanding around fundamental legal requirements
  • An absence of reliable advice and support around billing – even from Medicare
  • Doctors are afraid of making billing mistakes
  • Unmet opportunities for improvement 
Lead author Dr Margaret Faux, who has completed a PhD thesis at the UTS on Medicare claiming and compliance, said the findings indicate that the system needs ‘urgent reform’.
‘It’s an unpalatable truth that Medicare is in very poor shape [and] compliance has become almost impossible for doctors,’ she said.
‘A single Medicare service in Australia can be the subject of more than 30 different payment rates, multiple claiming methods and myriad rules, [and] continual changes due to COVID-19, such as those around telehealth, also add to the confusion.’
Dr Faux also describes the current policing strategies employed by the Department of Health (DoH) as ‘punitive’, and ‘not fit for purpose’.
The research is the first qualitative study to examine the experiences of medical practitioners in Australia.
Tasmanian GP and practice owner, Dr Emil Djakic, who is a member of the RACGP’s Expert Committee – Funding and Health System Reform (REC–FHSR), said the findings are not surprising.
He told newsGP that despite being ‘fairly MBS literate’, he still struggles to navigate the system.
‘It’s 15 years now since the Team Care Arrangement item number [was brought in] and at our practice we still sit down regularly, at least every three or four months, having interpretation discussions about that item number,’ Dr Djakic said.
‘We still find it difficult to work out exactly how we make sure that we comply or utilise it in its best intent.
‘GPs and particularly the younger cohort, our registrars and our new Fellows, are really struggling.’
Dr Djakic believes billing issues are largely due to the MBS being unnecessarily complex, describing it as ‘an unnavigable mess for all but a few’, which he says is underpinned by regularly shifting goalposts.
‘I believe most GPs are earnestly trying to make the best they can out of a mishmash of funding on [item] numbers,’ he said.
‘But Medicare moved from being an insurance tool for funding patients’ healthcare to a measurement of quality and standards that Government is trying to use to manipulate productivity and expenditure.
‘So it’s now trying to ride several horses and it’s doing it badly, and lots of people are falling off because it’s not fit for purpose anymore.’
Dr Djakic agrees that more emphasis needs to be placed on education. He said the REC–FHSR have made efforts to partner with the Department of Health to work on a ‘less punitive’ approach to better support GPs’ knowledge around the system.
‘We’d rather walk beside the department and help improve utilisation and better facilitate funding to flow to patients because, sadly, I fear that millions and millions of dollars that are available for patient healthcare is bypassing patients each year due to general practice literacy problems,’ he said.
‘But we need to accept that these descriptors are very difficult and there is a plethora of them now as well. I don’t know how a patient feels, but every time they leave my office … the same service seemingly has a different item number attached to it.
‘Now if you went down the shop and bought a carton of milk and every time you bought a carton of milk you were charged a different price, you’d be starting to think there’s something wrong with that supermarket.’
While Dr Djakic has in the past advocated for the MBS to be further embedded in the general practice curriculum, he says that will not fix the fundamental issues of a system that he says needs to be modernised – starting with equitable funding.
‘Incentives to jump through hoops [have] turned [this] into a “tail wagging the dog” scenario,’ he said.
‘People are doing item numbers sometimes because they know it will better access funding for the patient’s care, but perhaps not necessarily effecting much change in the patients. But it shouldn’t be designed that way – the patient’s insurance should be appropriate to the effective care you do on the day, all these other item numbers are just causing distractions.
‘This, again, talks to the focus on fee-for-service as the only modality – but it doesn’t work in chronic disease. So [personally], I’m up for wholesale tearing up the MBS and starting again, at least in the GP space.’
While the new research does not advocate for a complete redesign of Medicare, Dr Faux says the study makes clear that a multipronged approach is required to better equip doctors to manage their compliance obligations.
In her PhD, she has put forward 27 recommendations covering regulatory, educational and digital reforms to help modernise and streamline the system.
‘Doctors currently have no choice but to try and comply with an incomprehensible system that they do not understand and feel powerless to change,’ Dr Faux said.
‘Without reform, the Government can expect no improvement in leakage and non-compliance.’
RACGP members can access a range of useful resources on Medicare interpretation and compliance through the RACGP website, including: Log in below to join the conversation.

compliance Department of Health education item numbers MBS Medicare structural reform

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Dr Waldemar Andrzej Bogacki   25/01/2022 7:58:00 AM

The only logical step would be to stop billing Medicare but bill the patient. In initial period is not so important how much you bill but WHOM you bill in private practice. This looks like unthinkable in today situation but many other private health provider billing are billing patients/clients and are not concern about refund pay by insurance organisation what in fact Medicare is. In many countries private doctors are billing patient directly ( in very simple way) and patient are lodging claim with insurance company/organisation. Having insurer outlet in your reception area -(like many dentist)- for patient convenience- do not influence your billing. Patient are client of Medicare NOT A DOCTORS, and Medicare would need to find simple , logical way to refund patient or ... will be replaced. Something to think about after 40+ years unexplainable slavery to Medicare.

Dr Jeremy Simpson So   25/01/2022 8:31:40 AM

The college of GPs also has done a very poor job of helping its own profession navigate the minefield that is MBS, so much so that the space is taken up by private GPs and other companies that charge an arm and a leg for in person sessions to interpret the mbs and aid in billing optimisation.

The most obvious evidence is included in this article at the bottom where it says members of racgp have access to a range of helpful resources with links below, all linking to federal governmental websites which the public can access that has nothing to do with the college at all. Misrepresentation and outright lying to spin the truth in an attempt to hide an obvious fact that the college is dropping the ball in supporting and representing GPs.

Dr Peter Thomas Ryder   25/01/2022 9:28:12 AM

Hhooray! That’s the most sensible thing I’ve read about the MBS schedule in years. Us older GP’s remember when it consisted just of a set of simple consult items based on time, and procedure items! The bureaucratic micromanagement that endlessly subdivides everything we do , with each item having its own verbose descriptor, really has become a nightmare. Mental health? Add a set of item numbers. VR ? Add a set of item numbers, Eating disorders? Add a set of item numbers. Blood borne viruses ? Add a set of item numbers … etc etc. Knock it over and start again.

Anonymous   25/01/2022 10:23:22 AM

Education of numbers and compliance is not going to help. Even if GP start doing everything perfectly, the compliance staff employed will make up something to catch doctors in order to justify their jobs. It’s not their fault either. A reform is needed
The confidence of GP is low. The activitities and fines are based on subjective opinions and each doctor is vulnerable.
As it is subjective, there is no defence at all against it. You either accept fines or be reported to AHPRA or fight a defenceless case where no one has ever won. It will continue to do a lot of damage in name of saving dollars. I hope our health minister is aware of it and a reform is considered.
A GP charges patient his consultation fees and Medicare is helping patient and not GP in paying rebate of the fee. If Medicare is not happy with rebate paid, then it should ask patient to repay the rebate to government and not the GP to repay his consult fee. We should be more worried about patient care than Medicare numbers

Dr Anjum Ahmed Shaikh   25/01/2022 6:50:59 PM

There should be only 4 item numbers. Item 3, 23, 36 and 44. All consultations should be based on time spent with the patient.

Dr Henri Gustav Becker   25/01/2022 9:51:12 PM

I had presented a model of payment at the 2017 RACGP meeting which
was accepted as topic of discussion.
It was never discussed .
the model would be an hybrid model combining PMPM payment with a fee for service payment for procedures requiring more expertise or time .
doctors are not created equal and all medical acts not have the same value
the model preserves each one choices ,guarantees monthly payment , it also binds the patient to the practice ,thereby giving a dollar value to each practice , most importantly it encourages GPs to orientate continuous professional development towards new sets of services ,and potentially reduces the need for specialist referral .
under such model the gap payment is also preserved.
The cost of billing is also reduced , and a check in the mail covering your overhead when you return from vacation
Also we need to think about preserving FFS for rural and remote medicine because these doctors by their location need to be rewarded for needed skills

A.Prof Christopher David Hogan   26/01/2022 1:14:28 AM

A study with a sample size of 27 is not robust but it is interesting & should generate further investigations.
The various flavoured governments over the last 20 years have continued a policy of freeze, squeeze & obsfuscate for Medicare seeing health as an expense to be controlled rather than as an asset to be nurtured.
We have only one choice & that is to reject UNIVERSAL bulk billing- only then will they see GPs as being serious about the need for reform.