GPs push back against alleged $8 billion Medicare ‘rort’

Matt Woodley

17/10/2022 4:58:09 PM

The claim has triggered an investigation into the Department of Health and Aged Care’s existing compliance and audit programs.

Medicare card with money.
Around $8 billion is leaking from Medicare each year due to incorrect billing or deliberate fraud, Medicare compliance experts have alleged.

Around $8 billion is leaking from Medicare each year due to incorrect billing or deliberate fraud, Medicare compliance experts have alleged in a new report produced by Nine Newspapers and the ABC.
The investigation claims approximately 30% of Medicare’s annual $28 billion budget is being wasted by Australia’s doctors, based on estimates from lawyer and researcher Dr Margaret Faux which have been supported by former Professional Services Review (PSR) head Dr Tony Webber.
‘The reality is anywhere where you’ve got a huge pot of money that is super easy to access, you are going to get bad actors building business models just taking the money unlawfully,’ Dr Faux told the joint investigation.
‘And it’s a huge problem in the Medicare system.’
Dr Faux went on to say that a 2020 Australian National Audit Office (ANAO) assessment that Medicare non-compliance costs up to $2.2 billion per year grossly underestimates the issue.
She believes inappropriate billing occurs in all areas of the health sector including among GPs, surgeons, pathologists, anaesthetists, radiologists and dentists who use the child dental benefit scheme.
‘Aged care facilities have some of the greatest vulnerabilities to Medicare fraud,’ Dr Faux said.
‘Billing dead people, billing for ward rounds that didn’t happen or billing residents who are cognitively impaired and don’t have a recollection of what was discussed make it an area of concern.’
RACGP President Adjunct Professor Karen Price told newsGP it is difficult to comment on the veracity of the claims without seeing the evidence behind them, but noted they appear to have been extrapolated from limited data.
‘There are a range of views in this discussion and some very loud opinions,’ she said.
‘We would support an investigation into the problem, if there is more concrete evidence provided to support one.’

Professor Price also referenced the four layers of compliance that GPs and other medical specialists are already subjected to and said if Dr Faux’s $8 billion claim is correct, it would mean that existing government processes are inadequate.
‘I would caution against conflating billing errors made by practitioners struggling with the complexity of Medicare with deliberate attempts to defraud taxpayers,’ she said.
‘It is important to recognise that in many instances, incorrect billing of Medicare is not an indication that patients are receiving inappropriate and sub-optimal care,’ she said.
‘We have been saying for a long time that urgent reforms are needed … many GPs are very concerned about the complexity of Medicare.’
While no further evidence had emerged at the time of publication, Federal Health and Aged Care Minister Mark Butler told reporters he has already commissioned a report into the alleged findings, saying it is important to ensure that every dollar in Medicare is spent directly on patient care.
‘I’ve asked my department to provide me with an analysis of Dr Faux’s work, and a report on the department’s existing compliance, audit and Professional Services Review programs,’ he said in a statement.
‘All governments must apply strict compliance standards to any publicly funded system – including Medicare – to ensure that the small minority that do the wrong thing are picked up quickly and dealt with.’
The report was released a week before Labor releases its first Budget, which the RACGP has said should include greater support for general practice – including increased Medicare funding. When questioned about the alleged fraud, Federal Treasurer Jim Chalmers said the claims would be ‘absolutely atrocious’ if proven correct.
‘They’re very concerning reports, very troubling revelations. And something that we will get to the bottom of,’ he said.
‘Every dollar rorted, whether it’s Medicare or the NDIS, is a dollar thieved from people who need and deserve good healthcare.
‘We do need to do more work here to make sure that our defences against people who want to rort and thieve from government programs are cracked down on. We’ll do that work.’
However, GPs have also responded to the report, with many, including NSW GP Dr Tim Senior, taking to Twitter to question whether it appropriately characterises the situation.
‘Any health system needs a well-funded primary care sector to work well. I’m pretty sure that anecdotal stories of waste in an underfunded GP system is not the issue,’ Dr Senior Tweeted.
‘The real story here is not one of rorting Medicare. The real story is of GPs trying to provide care to patients while Medicare makes it harder and harder.’ It is a point supported by Professor Price, who said there is a ‘big difference’ between rorting the system and not meeting requirements due to excessive red tape.
‘MBS item descriptors and requirements are overly prescriptive and focus on administrative processes as opposed to quality patient care,’ she said.
‘Guidance on appropriate use of MBS items can also be ambiguous and contradictory and many providers feel they have been unfairly targeted by compliance activities, when in fact they have legitimate reasons for billing or prescribing a certain way.
‘The RACGP is supportive of Medicare compliance educative processes focusing on prevention of incorrect claiming, rather than punitive measures and blunt instruments which can distract providers from delivering appropriate and high-quality care to patients.’
The RACGP’s recent Health of the Nation report also indicates there is widespread uncertainty among GPs regarding billing practices, with two-thirds of respondents describing ‘understanding and adhering to regulatory changes’ as a significant challenge.
This was supported by 47% of respondents saying they either avoid providing certain services or claiming certain patient rebates due to Medicare compliance fears.
Log in below to join the conversation.

compliance Medicare Professional Services Review

newsGP weekly poll Would the reintroduction of MBS items for GPs to trace and report on electrocardiogram (ECGs) be beneficial to patients?


Login to comment

Dr Arshad Hussain Merchant   18/10/2022 6:48:55 AM

I am disappointed with the report and allegations on professional… I have a very simple solution = Stop providing bulk billing and only do privately and let patients deal with the Medicare and their politicians..
We are absolutely in the dark hole and rather helping, these reports are damaging to our moral values and character and a political stunt…
So I demand RACGP and colleagues to stop bulk billing all together

Dr Michael Lucas Bailey   18/10/2022 7:19:31 AM

Public hospital named referrals.

Dr Megan Elisabeth Barrett   18/10/2022 7:39:29 AM

I don't get why everyone is so horrified to hear this. Surely we have all spent an hour doing a careful mhcp or gpmp only to get the item number rejected by Medicare because our patient went to a gp down the road and they gave her a script dor her cellulite and billed a 721&723 ? When you ask for a copy of it from that GP it is a template on the patient's file never filled in and never consented to. Or surely we know of the GP who walks around the nursing home every week and nods at every person there and then bills them for a consultation? Thay is certainly not the majority of us. THE MAJORITY OF US ARE EITHER LEAVING GENERAL PRACTICE OR GOING UNDER FINANCIALLY. A VETY small minority have chosen Medicare fraud as their way of making Medicare sustainable for their patients who need them. I just want it to be known it is a few dishonest doctors. Not a routine occurrence .

Dr Anjum Ahmed Shaikh   18/10/2022 8:24:00 AM

I think medicare should be scrapped, and they should follow the NHS system where the GP surgery holds a list size, and the funding is based on the list size, rather than number and type of services offered. The doctors don't have to waste time in billing and chasing up individual payments.

SD   18/10/2022 8:33:58 AM

It is quite troubling to read this.
Many GP’s are turning away from General practice and aged care due to this. Increased compliance has been quite damaging to the profession and has lowered morale among doctors. Due to fear, many GP’s have turned part time or stopped seeing too many patients further exacerbating GP shortages. If the alleged rort is still happening, then it is either failed compliance or rort did not happen in the first place. It is frightening.

Dr Ian   18/10/2022 9:19:56 AM

If true it is at least 30,000 dollars a year that ought go to the honest “heavy lifters “ counting about 25,000 General practitioner’s in Australia not all full time and certainly at a 60,000 dollar grant for qualified General Practitioners in areas of Need .

Dr Catherine Louise Harding   18/10/2022 9:55:47 AM

I have no idea how one would or could bill for a dead person, it had never occurred to me that anyone would do such a thing but we deal regularly with the cognitively impaired who won’t remember or for that matter kids with normal cognition who won’t remember either. Does that mean we can’t bill for seeing them! It has been well demonstrated that much of what happens is forgotten on the walk back to reception anyway so relying on the patient’s recollection is problematic.
Beware of block funding however, the grass can always appear greener on the other side. I remember when working in NZ being envious that my Australian colleagues could charge more for longer consultations! Once you have been given a budget to manage your patients the next thing is to budget for pathology or pharmacy and there WILL be a sinking lid so we will do more year by year but won’t get more money for it. The government will give us the hose, turn off the tap and we will be blamed when the water stops flowing !

Dr Bradley Arthur Olsen   18/10/2022 9:58:57 AM

Oh Dear " Billing residents who are cognitively impaired " gee whizz , have I been committing a crime for 30 years- perhaps I should just send them to DEM and Queensland health - that will make it cheaper!!!!!

Dr Kevin Matthew Reid   18/10/2022 11:35:21 AM

Most of the hundreds of doctors I have met and know personally are honest hard-working professionals.

Dr Peter James Strickland   18/10/2022 12:27:53 PM

Medicare needs to be scrapped --designed by bureaucrats, and does NOT support GPs or patients. Drs bulk-billing should now receive $55 plus per item 23, and $100 plus per Item 36 in 2022. All billing should be done directly to patients without any accounts needing to be sent out (too expensive). Originally, the best way was to have every patient bulk-billed in the first place, and the GP being able to place a fee on top of that amount to cover costs and income at the end of any consultation/procedure --it is a bloody insurance scheme set up by Whitlam (then Hawke), and NOT a fee GPs should charge. The RACGP and AMA have been very weak on all of the negotiations for now nearly 50 years --time to get rid of a system that attracts fraudsters, and bring back ethics and a decent supporting income to both attract GPs and give them also a decent viable income for their community service. Pensioners & parents CAN afford $5-20/consult in general above Medicare levels.

Dr Michael Denis Hodgett   18/10/2022 12:52:49 PM

I did a locum for a solo practitioner in a small town on the New England Highway 20 years ago and the receptionist asked me to sign Medicare forms for the clients in the local nursing home.
I said, “no” and she replied “the regular doctor charges them whether he sees them or not”
Go figure!

Dr Brendan Leslie   18/10/2022 7:25:14 PM

Great post by Dr Megan Barrett above, couldn’t agree more.

Dr Brendan Leslie   18/10/2022 9:04:42 PM

I completely agree with Dr Megan Barrett and have had similar experiences many times. I hope that anyone who deliberately rips Medicare off like that gets what they deserve. If honest mistakes start getting prosecuted rather than being given an opportunity to repay, well that’s a different story- let’s save our energy for that if it happens.

Dr Siva Kumar Raju Muppala   18/10/2022 9:25:31 PM

Not sure how this 8 billion rorting calculated. If they know how it happened, then recover the money instead of blaming doctors .

Dr Molapo William Selepe   19/10/2022 1:08:46 AM

Any compliance authority finds its legitimacy in openness, transparency, getting rid of the red tape and ambiguity. It is important to simplify the billing descriptors like you have with streamlined authorised prescriptions. If we don’t do this we end up vilifying our very frontline, the troopers who go into the trenches on a daily basis to keep Medicare afloat end up being misconstrued for crime based on ambiguous technicalities. Fraudulent transactions of over $2 billion make you think, perhaps it’s about time to overhaul the entire system. Are there so many leaky holes in the system to exsanguinate so much financial resource on a yearly basis? We need to protect that $28 billion Medicare reservoir so that every citizen has the confidence to tap into it at the time of need like I seen in so many of our clients who have died this year had they been in another country. Medicare saves lives and is one of the best healthcare systems in the world…

Dr S   21/10/2022 11:23:48 PM

This is clearly an attempt by the Government and Bureaucracy to Change the narrative as GPs were Finally getting some sympathy from the public regarding the inadequacy of medicare rebates , the rebate freeze etc
Added was the pressure on the local MPs from angry constituents about the lack of timely, high quality and bulk billed GP services. Lo and behold- what better timing to bring in the media and smash the”Greedy doctors”. The solution is very simple- Private billing for all patients, with the ensuing shortage of GPs , bulk billing and Government funded capitation type services, patient enrollment etc need not be taken up, if Gps are to survive and retain the respect of their patients. With no bulk billing, there is no room for medicare errors, audits and allegations of Fraud. Problem solved
The Government can make arrangements to care for those that can’t afford to pay

Dr Rahul Kalon   29/10/2022 12:13:27 AM

Surely there is a rort we all are aware You be lying otherwise