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GPs push back against alleged $8 billion Medicare ‘rort’
The claim has triggered an investigation into the Department of Health and Aged Care’s existing compliance and audit programs.
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.
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