Last Monday the ABC and The Nine News Outlets made a big splash with the following headlines:
‘Medicare is haemorrhaging’: The rorts and waste costing taxpayers billions of dollars a year
By Adele Ferguson and Chris Gillett
October 17, 2022 — 5.00am
The revelations come as GPs lobby the federal Labor government to boost Medicare funding and increase rebates, claiming the system is in crisis as patients struggle to find a bulk-billing doctor.
A joint investigation by The Sydney Morning Herald, The Age and the ABC’s 7.30 program has uncovered flaws in Medicare’s systems that make it easy to rort and almost impossible to detect fraud, incorrect payments and errors.
The leakage is estimated by some to represent nearly 30 per cent of Medicare’s annual budget, or about $8 billion a year.
The rorting, which continues largely unpunished, includes a doctor caught in February charging for dead people in aged care homes, a doctor prescribing drug addicts with oxycodone without due care and radiologists over-servicing terminally ill cancer patients.
The fraud and waste have been allowed to occur for decades despite repeated warnings to successive governments from experts, including Margaret Faux, who has a PhD in Medicare claiming and compliance.
“I think most Australians believe that doctors are honest people,” Faux said. “And I’d like to think that most of them are. But 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. And it’s a huge problem in the Medicare system.”
Faux’s estimate of $8 billion annual leakage from Medicare is in line with Kathryn Flynn’s PhD published in 2004, which noted some believed fraud and inappropriate practice could be as high as 25 per cent.
Webber said that he saw egregious misconduct from within his profession, including the ordering of pathology tests which were inappropriate for the clinical condition and had a huge impact on the health budget.
“And many of these private radiotherapy clinics are run by corporations, where their shareholders are overseas,” he said. “Medicare was never designed to both reimburse the doctor and an overseas shareholder.”
When Webber raised his concerns with health ministers from both sides of politics, or the federal health department, he was shut down.
“The administration of Medicare is a very political creature to work with, and it can be very difficult for change to occur,” he said.
“If one side of politics decides to make a radical change, the other side of politics can use it to beat them over the head in an election.”
A report by the Australian National Audit Office into Medicare compliance released in November 2020 estimated the cost of health provider non-compliance at up to $2.2 billion.
For comparison, that is about double the ABC’s annual taxpayer funding. Foreign aid costs about $4.5 billion a year, the Royal Australian Air Force about $7.8 billion and the CSIRO about $1.4 billion.
Faux has warned the 2020 estimate grossly underestimates the problem.
The inappropriate billing occurs in all areas of the health sector including GPs, surgeons, pathologists, anaesthetists, radiologists and dentists who use the child dental benefit scheme.
She said the doctor busted in February for billing Medicare for dead people in government-funded aged care facilities for consultations of varying lengths was not an isolated case. “Aged care facilities have some of the greatest vulnerabilities to Medicare fraud,” she 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,” she said.
Hundreds of millions of Medicare claims are made each year – many of them are under $100 – but the high-volume, low-dollar transactions make it easy for fraud to fly under the radar.
Faux believes wrongful claims are being applied to millions of billings.
“We removed consumers and took them out of the transaction,” she said of changes to the administration of Medicare by doctors a few years ago. “Patients used to sign a piece of paper, so we knew they were there, now they don’t even do that, so you don’t know how much is billed when you walk out the door, and few check their Medicare records.”
Her business, Synapse Medical Services, is paid by doctors, hospitals and corporate medical practices to process their Medicare bills. Faux said she constantly finds problems in client billing practices and even her own personal Medicare records, which include services she never had and services that were recorded as having taken longer than they did to attract a higher Medicare fee.
A bulk-bill GP consult of less than 20 minutes is $39.75 and a bulk-bill GP consult that lasts at least 20 minutes is $76.95.
“The bottom line is we don’t know exactly how much is fraud, deliberate abuse and how much is errors. Whether it’s deliberate or unintentional, it has to stop,” she said.
“As long as a practitioner stays within the bell curve, they are very unlikely to come to the attention of Medicare, and be audited, even if 100 per cent of their claims are fraudulent.”
Faux said the government tells Australians we have the best health system in the world. “But unfortunately the reality is very different. Medicare is actually haemorrhaging. It is very badly broken and in need of urgent reform.”
Some of the biggest offenders are corporate health clinics including pathology chains and GP super clinics, as well as public hospitals where errors and fraud have largely been left unchecked.
Documents obtained by the Herald, The Age and 7.30 show an online telehealth company was charging some patients fees of $38 or $50 and also bulk-billing them, which is illegal under the Health Insurance Act. Some records show the GP had overstated the length of the consultation, which attracts a higher rebate.
Separately, Tweed Health for Everyone in northern NSW, one of the country’s largest super clinics, alleged to have claimed hundreds of thousands of dollars – and possibly more than $1 million – for services that weren’t performed or potentially shouldn’t have been claimed.
Patients were allegedly misdiagnosed with diabetes for extra Medicare billings, patient records falsified and targets set for a certain number of monthly wound debridements, a procedure for treating a wound in the skin that attracts certain Medicare reimbursements of more than $250.
A former co-founder, director and GP at the clinic, Dr Austin Sterne, said that in 2015 he first discovered questionable Medicare billing. To support his suspicions, he pulled out the CCTV footage in the waiting room and compared it to the clinic’s appointment book, patient records and billings. He even called some patients, who denied they had seen the practitioner.
He informed the clinic, but they were reluctant to act. In one email he wrote: “The CCTV footage shows that [a health practitioner] bills 40 mins for each consult but typically spends only 10-15 minutes with the patient. Typically, [the practitioner] is billing $800-$900 per day but only legally should be claiming approximately $250 per day. On Monday, she should have claimed $50 but claimed $656 instead!”
Months later an investigation was launched and the practitioner resigned but continued to see some patients. Sterne said after getting legal advice, the clinic eventually informed Medicare that some billings had been claimed incorrectly but did not inform Medicare of the suspected fraudulent billing.
Sterne was also concerned about the way the clinic was claiming wound debridements, which didn’t fit Medicare criteria to qualify for the payment.
He said the practice was billing between $123,000 to $266,064 a year in wound debridements alone.
“The service was attractive for the GPs as the debridements paid $277 for only a couple of minutes of the GP’s time, with a wound care specialist nurse doing the debridement itself,” he said.
At one point in 2016, the clinic’s then-CEO prepared a spreadsheet for the wound business saying the clinic should double the number of wound debridements to make the numbers more profitable for the business. The CEO said 80 of the procedures a month should become the “target” because “we do not wish to reduce GP income”.
Sterne left in December 2017 after legal action that culminated in him signing a deed of release. Since then, there has been a change in senior management and the board.
In response to a series of questions, the clinic’s spokesman, who joined the clinic in 2013, said the questions refer to a period before the change of ownership and management of the clinic. He said the clinic takes compliance “extremely seriously and conducts regular training for doctors, providing them with continuous updates on compliance with the requirements of the Medicare Benefits Schedule.”
…..
Watch the ABC’s 7.30 program on Monday, October 17 for more.
Lots more here:
Wow I thought, but then thought that figure of $8 billion sounds pretty high and wondered what the truth was.
Next we had the Health Minister and the AMA reacting:
Government to investigate claims doctors scam billions from Medicare
A joint investigation by The Sydney Morning Herald, The Age and the ABC’s 7.30 program on Monday said flaws in the Medicare systems meant doctors were rorting about $8 billion per year from Medicare, or 30 per cent of the program’s budget.
Speaking on Tuesday morning, Mr Butler said that figure seemed “extraordinarily high”.
“It’s way out of whack with any other figure that’s ever been provided to government including as I said by the national audit office, that only did a review of the program a few years ago,” Mr Butler told the ABC.
“But I’m taking it seriously, so I’ve asked the department for some formal analysis of the work.”
The $8 billion estimate is from Margaret Faux, an expert with a PhD in Medicare claiming and compliance.
The medical profession slammed allegations that 30 per cent of Medicare claims were non-compliant.
The Australian Medical Association (AMA) said the reports were an unjustified slur on the medical profession.
‘Undeserved attack’
AMA president Steve Robson said doctors would be sickened by an “undeserved attack” based on “anecdotes and individual cases”.
“The AMA works closely with the Department of Health on compliance, and we have never seen any concerns or numbers that would support the figures reported today,” Professor Robson said on Monday.
“We do not tolerate fraud and examples of fraud should be tackled and stamped out – but the figures reported today are grossly inflated.”
An Australian National Audit Office’s review into Medicare compliance in 2020 estimated that non-compliance was between $366 million and $2.2 billion annually, substantially below Dr Faux’s estimate.
In the 2019 financial year, the Health Department conducted 57 investigations into allegations of serious or intentional misuse of Medicare and recovered $49.3 million in claims that should not have been paid, the ANAO said.
‘The odd bad apple’
Mr Butler said he had asked the Health Department for an analysis of Dr Faux’s PhD thesis.
More here:
and here:
AMA Statement on Medicare allegations
Published 17 October 2022
The AMA is extraordinarily disappointed at the allegations today in the media suggesting that up to $8b is being defrauded each year from Medicare by health professionals including doctors.
These claims are an unjustified slur on the medical profession, with the vast majority of doctors doing the right thing by their patients and by Medicare rules.
Our health system is built around universal access to health care that Medicare supports, and the AMA supports effective stewardship of this Medicare funding.
The AMA has worked with the Government to ensure that Medicare requirements are clearer for doctors and supported initiatives to ensure that the Department of Health has effective tools to police and detect fraud.
The AMA meets regularly with the Department of Health, which has sophisticated analytical tools, and understands that there is no evidence of the widespread fraud suggested in today’s media.
The Department of Health has extensive data at its disposal and the AMA believes that this should guide Medicare compliance activities as opposed to the anecdotal evidence of a small number of individuals.
Where evidence of fraud is found, the AMA fully supports efforts to stamp this out including referral top the Professional Services Review when required.
AMA President Professor Steve Robson said:
“Australia’s doctors have worked incredibly hard through COVID – treating Australians during lockdown, rolling out the nation’s vaccine efforts, putting themselves at risk every day to treat COVID patients on the front line – so today’s coverage is as appalling as it is inaccurate.
“Doctors will be sickened by today’s reporting which is an undeserved attack on the whole profession based very much on anecdotes and individual cases.
“The vast majority of doctors do the right thing, and are working hard for their patients under tremendous pressure within the system.
“The AMA works closely with the Department of Health on compliance and we have never seen any concerns or numbers that would support the figures reported today.
“We do not tolerate fraud and examples of fraud should be tackled and stamped out - but the figures reported today are grossly inflated."
Here is the link:
https://www.ama.com.au/media/ama-statement-medicare-allegations
I was looking forward to a move away from all the estimates and a clear statement as to just what the actual number of the spend was and reliable clarity on what the true figures were for waste and fraud.
Sadly it has become clear the Government / DOH do not actually know just what the waste and fraud figures are.
Given the huge spend of millions of dollars we see on the Medicare systems and technology – there was a $100M upgrade in the last Budget for their systems – on would expect better.
Surely with the analytics available today and the availability of case by case data from the Medicare Billing by both patient and clinician we must ask why the answers are not readily to hand. I bet Coles and Woolworths know to the dollar their wastage as fraud levels!
I really think when you are paying out $28 Billion of our dollars you ought have a pretty complete picture of where it is all going etc. or do I expect too much?
The Minister should have been able
to promptly say a good deal more than the ‘estimates seemed high’! We need to
do a lot better. Bottom line seems to be the technology can't do what we need!
David.
1 comment:
Looks as though the government understands Medicare data as well as it understands myhr data, NDIS data and robodebt data - very poorly.
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