Many thanks to Margaret Faux for this précis of an article published in the Internal Medicine Journal on 4 February 2015 No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?

Margaret Faux writes:

In an article recently published in the Internal Medicine Journal, my co-authors and I have summarised a selection of available literature concerning medical practitioners’ understanding of Medicare claiming and compliance.

The seed of the paper originated in a systematic review of literature in this area which found that despite much commentary and opinion, little if any empirical research exists on this topic.

We examined the complexity of day-to-day Medicare claiming, which has become labyrinthine to the point where it is beyond the comprehension of many, including medical practitioners who are largely dependent on Medicare for their livelihoods. The literature proffers that between $1-3 billion is leaked from Medicare each year as a result of inappropriate claiming (approximately 5-15% of total Medicare expenditure), yet no research has ever sought to critically analyse the potential causes of this phenomenon beyond suggestions of deliberate misuse of the system by rogue clinicians.

There exists an overarching assumption that doctors possess a high level of legal literacy in relation to Medicare claiming and compliance. However, the regulatory framework is complex such that a single medical service can be the subject of thirty different payment rates, numerous claiming methods and a plethora of rules, with severe penalties for incorrect claiming, including criminal sanctions. The evidence also suggests that despite Medicare claiming being a component of almost every interaction between a doctor and a patient in Australia, doctors receive little formal preparation in the proper use of Australia’s tax payer funded insurance scheme.

The administrative infrastructure required to support practitioners in relation to their claiming activities appears to have reduced over time, to the point where reliable advice and support is not readily available, and even senior members of the Australian judiciary have formed differing views concerning key elements of the operation of the scheme.

The majority of published manuscripts discussing inefficiencies in medical billing, particularly commentaries in peer-reviewed journals, are quick to highlight medical practitioner rorting as a major factor (and sometimes the major factor) for Medicare billing inefficiencies. Our paper highlights that there may be other hypotheses to explain inefficiencies in medical billing beyond individual practitioner rorting. This approach acknowledges the complexity of the system and suggests that further rigorous, unbiased and critical exploration of this issue is needed.

In the spring of 2007 the then Minister for Human Services announced that $250 million in Medicare program savings had been achieved in the previous year through an education program for providers. This suggests a causal link between medical practitioner access to Medicare education and significant costs savings, and gives rise to an important question concerning why the current government has prioritised co-payments over alternative proven measures that do not impose burdens on consumers.

Other jurisdictions such as the U.S (where the 2012 Medicare services improper payments rate was reported as 8.5%) have recognised the need for the development of a national curriculum on the topic of claiming and compliance.

Incorrect claiming is one of a number of reasons cited in the literature as contributing to Medicare’s current financial pressures. Others include an ageing population, the higher incidence of chronic disease and the increased use of expensive tests and treatments by doctors. However, these consumer changes in healthcare are a separate issue to inefficiencies associated with billing for those services, and both must be included in any discussion on system reform.

We conclude that research examining medical practitioner experiences and understanding regarding Medicare claiming and compliance is urgently required if we are to responsibly modernise Medicare, and that without further examination of this important topic, proposed Medicare reforms (including co-payments) may do nothing more than increase the incidence of both deliberate and unintentional non-compliance.

The new Health Minister Susan Ley has been charged with repairing the damage to the Medicare debate brought about by ideologues. She will need to consult widely, it is true, but perhaps more importantly she will need to look within, because Medicare’s sustainability may depend more on internal efficiencies than artificially created price signals. As John Hewson said during the recent spill motion – ‘let’s hope politics gives way to policy’.






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