Under-billing not part of Medicare review terms

A major concern GPs have about Medicare, under-billing, has not been included in the terms of independent probe into the system’s integrity – a move described by the RACGP as disappointing in a recent submission to the review.
 
Instead, the college notes the review concentrates almost exclusively on ‘quantifying the value of fraud and non-compliance’, while neglecting to consider the ‘widespread impact’ of the phenomenon.
 
In documents sent to Dr Pradeep Philip, a health economist and experienced public service bureaucrat who was appointed Chair of the Review of Medicare Integrity and Compliance, the RACGP also cites the impact of complex and confusing rules on GPs and patient care.
 
GPs repeatedly referenced the issue of under-billing when newsGP sought feedback after the so-called ‘Medicare rorts’ coverage first emerged in October last year, when a joint Nine Newspapers and 7.30 investigation placed general practice processes at the centre of fraud allegations.
 
Almost all newsGP readers reported lost income due to Medicare under-billing in a poll last year, with 97% of 1425 respondents saying they missed out due to under-claiming available patient rebates.
 
That aspect of Medicare was not raised in the coverage, in which initial reports suggested up to $8 billion of funding could be lost to fraud and errors each year.
 
While the Federal Government queried the claimed scale of the issue, with Health and Aged Care Minister Mark Butler calling the figure ‘way out of whack’, the controversy nevertheless prompted the review to be called in November.
 
At the same time, many of the country’s most senior health professionals, including Department of Health and Aged Care Secretary Professor Brendan Murphy, said they had not found any evidence for the claims.
 
In a letter sent prior to a meeting this month with Dr Philip, RACGP President Dr Nicole Higgins outlined many of the Medicare issues encountered by general practices around the country.
 
Dr Higgins stated that the RACGP ‘has always supported ethical and responsible billing practices’ but reiterated its long-held position that the MBS is ‘unnecessarily complex and does not reflect the way GPs deliver person-centred, comprehensive, and holistic healthcare’.
 
‘This complexity is contributing to inadvertent billing errors and technical non-compliance, rather than deliberate non-compliance,’ the letter states.
 
The letter also notes that the Review is thought to be looking into susceptibility to Medicare fraud within different claiming channels. While the college states that complexity is a greater concern, it suggests that claiming channels should be able to reject non-compliant claims immediately where possible – a move that ‘would prevent a great deal of stress and worry’.
 
In an appendix accompanying the letter, the college includes several specific examples of MBS complexity and confusing rules. It notes there is ‘no commitment’ to exploring the efficacy of compliance education approaches that ‘could reduce the regulatory burden on GPs’.
 
According to the submission, while compliance is a concern among 61% of GPs surveyed in the most recent Health of The Nation report, it is particularly acute for GPs in training, of whom four in five say it ‘worries them outside of their work day’.
 
The same report states that more than three in four GPs (77%) believe Medicare compliance deprives them of time caring for patients.
 
As a result, the RACGP has called for health professionals to be given the opportunity to adapt billing practices before being subject to an audit.
 
‘The last thing GPs need is an excessive regulatory burden that takes time away from patients who desperately need their help,’ Dr Higgins wrote in the college’s letter to the Review’s Chair.
 
More education is needed rather than ‘blunt instrument’ measures, the college contends, with the timing of compliance campaigns another concern raised.
 
One example given is the early 2021 COVID-19 telehealth compliance campaign, which at first looked to be targeting almost 30,000 GPs, a figure that was subsequently whittled down to around 500. 
 
‘The RACGP questioned the timing of this announcement, as at this stage GPs were still having to manage periodic outbreaks and continual changes to vaccine eligibility,’ the submission reads.
 
Inconsistency and confusion around guidelines that could shift with little notice is another theme, with the college citing the example of changes to the established clinical relationship rule.
 
‘A lack of clear communications around the established clinical relationship rule and exemptions remains an issue today,’ the submission states.
 
Dr Higgins also raised the ‘rorts’ coverage from last year in her letter, stating that she was ‘bitterly disappointed to read the baseless allegations levelled at our profession’.
 
The RACGP President described the stories as demonstrating ‘a clear lack of understanding of the Medicare compliance process and the various stages involved’. She gave the example of an ABC story citing the number of doctors investigated by the Professional Services Review (PSR) without any acknowledgment that the PSR only investigates the most serious cases of alleged non-compliance.
 
Dr Philip is due to file an interim report to the Federal Government by the end of January, with a final report expected by the end of February.
 
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MBS Medicare under-billing