Survey suggests huge scale of GP under-billing

An overwhelming majority of newsGP readers report losing income due to Medicare under-billing, according to the results of the latest poll.
 
More than 97% of the 1425 votes cast reported a proportion of income missed due to under-claiming available patient rebates.
 
Of those, by far the greatest proportion (708 votes, or 49.7% of the total) say they lose a figure amounting to more than 20% of their total income through under-billing each year. Of the rest, around 34% of readers indicate a loss of between a tenth and a fifth of earnings, while 14% said they lose up to 10% annually.
 
Only 3% of the respondents (42) indicate no under-billing losses.
 
The results of the poll, which is open to all newsGP readers, challenge the narrative of recent reports that have appeared in both Nine Newspapers and the ABC, many of which been headlined with accusations of rorts and fraud. 
 
Despite the substantial backlash to the reporting, Nine Newspapers appear to have doubled-down on the published claims.
 
Currently, a collection of 23 articles on both the Sydney Morning Herald and The Age websites appears under the banner ‘Medicare Rorts’, including an introduction saying that ‘billions of dollars are being rorted from Medicare each year, including by billing dead people and falsifying patient records to boost profits’.
 
Many of the stories have included claims of $8 billion worth of annual Medicare fraud and waste, a figure that Dr Tim Senior, a GP who has been an outspoken critic of the recent coverage, believes is unsubstantiated.
 
He points to Productivity Commission reports, research by the Australian National Audit Office, as well as the PhD of Dr Margaret Faux, who was one of the main sources for the recent coverage.
 
‘None of them back up that figure of $8 billion,’ he told newsGP. ‘The thing has been plucked from the air, and it doesn’t match the experience of GPs actually doing Medicare billing every day.
 
‘The under-billing does match people’s experience, however. It matches the results of the Health of the Nation survey, it matches the results of your poll.
 
‘People tend to err on the side of under-billing when there’s any doubt, just in order to make sure that they’re staying the right side of billing appropriately.
 
‘Our patients lose out on the appropriate rebates as a result.’
 
According to the latest Health of the Nation Report, 47% of GPs said they either avoided certain services or claiming patient rebates, despite providing services, due to fear of Medicare compliance ramifications.
 
The Chair of the RACGP Business Sustainability Working Group, Dr Emil Djakic, believes there should be a closer look at the scale of income lost due to under-billing.
 
‘There could be more useful research to be done in this area to show another facet of the failings of Medicare,’ he told newsGP.
 
‘In our webinars, lots of questions seem to be fairly naive questions, but are really just a reflection of how floundering our profession is in a Medicare seascape that’s been changing so rapidly over the last few years – not to mention the confusion that patients have.’
 
He agrees that consistently unusual billing habits should draw the attention of the Professional Services Review.
 
‘They rightly need to attract interest, and either have their argument tested for validity or be called out for what is fraudulent behaviour,’ he said.
 
However, Dr Djakic believes the issue of under-billing is at least as significant as fraud.
 
‘There’s almost an inverse law that applies: the busier I get, the less sophistication I use in Medicare when I will default back to an item 23 as the fallback position,’ he said.
 
The impact of under-billing on patients
Like Dr Senior, Dr Djakic believes patients are missing out on appropriate care due to bureaucracy and compliance fears.
 
‘My patients sit here and are very bemused when they watch me have to click a mouse 56 times to get an authority medication through PBS that they’ve been getting every three months for the last 10 years,’ he said.
 
‘There’s a whole lot of inefficiencies.
 
‘The thing I really worry about is the lost opportunity for funding to reach general practice, which is a lost opportunity for patients to get access to services.
 
‘Time lost in bureaucracy … is time lost in accessibility for patients to general practice.’
 
Dr Djakic also believes that Medicare complexity is putting people off general practice even more than the lower remuneration compared to other specialities.
 
‘They’re very unhappy with the complexity of Medicare, they’re unhappy with the complexity of the PBS, they’re unhappy with the complexity of doing the job – not the medicine part, but the significant amount of compliance and regulatory frameworks that have now evolved around it,’ he said.
 
‘I’ve got colleagues who are even choosing to not use the team care arrangement process when they can, because it’s just too difficult.
 
‘That’s a very sad reflection on the nature of the insurance system that’s in place for patients, that it ends up being so complex that people either don’t understand it or don’t use it to its best advantage to serve patients with the services they need.’
 
Given that, it is unsurprising that Dr Djakic hopes simplification of the system will be one of the key outcomes stemming from the Strengthening Medicare Taskforce that is currently meeting and due to report by the end of the year.
 
As it stands, he believes Medicare does not have an effective handle over chronic disease management and complexity of patients seen by general practice.
 
‘A lot of other industries have undergone reform relating to this very thing. And the end result is they look different to what they did 30 years ago,’ Dr Djakic said.
 
‘We have to undergo the same reform and the insurance system that’s there to serve patients has to undergo similar reform to ensure that it’s providing value for the taxpayer, and allowing general practice to function in the way it needs to, which is in its very fluid way.’
 
Reform likely to be challenging
Both Dr Djakic and Dr Senior acknowledge that reform will not be simple.
 
Dr Senior said any system should not be based on financial imperatives for the doctor or the practice, but on the best interests of patients – and worries reform could include funding cuts.
 
‘What we deliver is very difficult to measure, and yet we know the research evidence shows it’s the most effective part of the health system,’ he said.
 
‘The effect of the Strengthening Medicare Taskforce has to be strengthening not just Medicare, but also strengthening general practice and primary care.’
 
He points to other knock-on effects of a stressed primary care system, such as more expensive hospitalisations, greater chances for patients to develop chronic disease, and an increasing reliance on NDIS or Centrelink payments.
 
‘At the moment rebates are clearly not high enough for providing that care,’ Dr Senior said.
 
‘I would argue it’s more important that we have adequate funding, and that we talk about the mechanisms for generating that and the mechanisms for managing complexity and multimorbidity, rather than just an argument about increasing rebates.
 
‘If you want to run a more effective, fairer and cheaper health system, you have to fund primary care adequately.’
 
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