College responds to Medicare integrity report

A newly published review of Medicare compliance and integrity has been welcomed by RACGP President Dr Nicole Higgins, who hopes the 77-page report will lead to change for a system she describes as ‘in critical need of simplification’.
 
The Independent Review of Medicare Integrity and Compliance identified several key failings with the current system, including unnecessary complexity and a lack of clarity related to many aspects of the compliance process.
 
It was compiled by health economist and former senior bureaucrat Dr Pradeep Philip, who wrote that the system is ‘not currently fit for purpose’.
 
‘The RACGP agrees that Australia’s health funding system is fragmented and disjointed and in critical need of simplification,’ Dr Higgins said.
 
‘GPs are doing a tremendous job navigating a fiendishly complex Medicare Benefits Schedule, which includes around 6000 items, and a health department that continues to initiate poorly targeted compliance campaigns.
 
‘Any compliance burden takes GPs away from their core job, which is to provide care to patients, and it is absolutely essential that balance is taken into account by regulators.’ 
 
The review, which was commissioned as a result of widespread coverage of alleged Medicare fraud, suggested leakage of $1.5–3 billion is ‘entirely feasible’.
 
A headline figure of $8 billion was widely reported, and strongly contested by GPs, leading to the commissioning of the review.
 
‘At present, it is my view that a significant part of the leakage in the Medicare payment system stems from noncompliance errors rather than premeditated fraud,’ Dr Philip wrote.
 
‘Indeed, one could argue that there is a significant amount of “fear” of the compliance regime, notwithstanding it is not as far reaching or effective as it could or should be in practice.’
 
He also said the legislative basis of Medicare is fast becoming out of date and does not reflect the changing healthcare needs and modes of delivery.
 
Dr Higgins agrees with the description of GPs’ perception of the regulatory system.
 
‘As Dr Philip says, there is a lot of fear of the compliance regime, which is actually leading to GPs under-billing Medicare,’ she said.
 
‘Every single day, GPs are having to decipher complex billing rules while trying to care for patients.
 
‘This is the responsibility of government to fix – not GPs.’
 
The review stressed the importance of improving education for GPs, which Dr Higgins pointed out has been a key point of the college’s recent advocacy.
 
The RACGP President also welcomed the acknowledgement that the estimates of leakage from the system come predominantly from honest billing errors rather than premeditated fraud.
 
‘It’s vital that the ABC and Nine newspapers recognise this, because their “investigation” severely damaged the morale of GPs and practice teams after several trying years managing patients during the pandemic,’ Dr Higgins said.
 
She committed to working with the Federal Government to improve the system.
 
‘GPs understand that Medicare is taxpayer-funded and needs to have appropriate governance and oversight,’ she said.
 
‘The RACGP is focused on solutions and boosting support for general practice care.
 
‘Any suggestion that we’re opposed to change is wrong.
 
‘GPs have no sympathy for anyone who deliberately defrauds Medicare, and supports any actions taken against those who do.’
 
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