Politicians are lighting us up with inflated bulk billing numbers. Medicare Bleeds Money | Fake Daisy

Ohen I explained to GPs that bundled billing for an IUD insertion and billing $150 separately for the same service was illegal, they were horrified. It had been their business model for years. Then when I explained to a patient that his GP had spent over 20 minutes doing a complex job, he was equally horrified, but for different reasons – the GP had apparently taken less than five minutes to write a prescription and request a blood test. It was last week.

I’ve been handling medical bills since Medicare started in 1984. Where I work is best described as the underbelly of Medicare. It’s a dark and confusing part of the healthcare system where patient journeys, treatments and procedures are converted into claims for payment. I’m basically shuffling money into the healthcare system, in an environment where no one trusts anyone and consumers are just confused and bewildered.

Even before I started a PhD in Medicare claims and compliance in 2012, it was obvious to me that Australian healthcare regulations had become a mess and that wholesale billing was broken.

When the government announces that 90% of Australians don’t pay GP fees, I’m sure most consumers would be scratching their heads wondering where all the bulk billing GPs are hiding.

GP bulk billing statistics are an important metric for measuring the health of our healthcare system, which is why the government often presents them as proof that Medicare is in good shape.

However, high wholesale billing rates do not necessarily indicate that Medicare is working well, and within the statistics lie many complex and poorly understood phenomena.

First, GP statistics count wards rather than patients, and patients may have more than one ward during a single GP visit. When a general practitioner provides more than one service, he does not have to bill both together and can choose the service billed. A common example is bulk billing for a consultation and billing a private fee to remove a skin lesion. There is no illegality, but this type of mixed invoicing falsifies the data because the consultation invoiced in mass falls into the statistics, but not the procedure. Thus, this patient will belong to the 90% group, even if he paid the same day. A study conducted by the RACGP in 2016 suggests that this phenomenon brings the statistics down to less than 69%. But it does not stop there.

There is also what I would call ethically dubious billing, caused by a system malfunction. The most common example is the repeated return of patients for additional appointments, for the sole purpose of enabling bulk billing. An example might be a patient who comes in for a pap smear, back pain, and needs a new prescription. All of this could and should be handled in one appointment, but if the GP brings the patient back multiple times, their income increases.

Then we come to non-compliant billing, which is a spectrum of behavior with criminal fraud on one side and unintentional errors on the other. The most common type of fraud in Australia occurs when a doctor knowingly wholesale charges for a service they have not provided. It is devilishly difficult to find and therefore to pursue. On the spectrum of illegality, away from fraud, we have what is called “up-coding”, where a doctor charges for a longer or more complex service than the one provided. That’s what the patient I mentioned earlier experienced – a five-minute consultation mass-billed as having taken over 20 minutes.

Going even further, we are now in non-compliant, but not fraudulent, territory. A good example is in this 2020 defamation case between two general practitioners. It’s a sobering read about GPs teaching their colleagues to charge incorrectly to maximize Medicare revenue. One of the GPs in the case described teaching fellow GPs to ‘pack and stack’ as many Medicare items as possible on each patient.

Medicare only reimburses services that patients need, so even if all services are provided, “packing and stacking” unnecessary services is not compliant.

All of these non-compliant behaviors show up in wholesale billing statistics. They artificially inflate our health care costs and are signs of system failure, not success.

The last major issue, which skews the data, is Bulk Billing and Billing Discrepancies as separate Eftpos transactions. Once upon a time there were GPs charged with criminal fraud for doing this, but an ill-conceived policy change many years ago changed all that, and the practice has now become so commonplace it’s akin to a stealth co-payment, i.e. hidden in plain sight.

As for the impact of this phenomenon on wholesale billing statistics, well, it’s actually very easy to quantify if we want to. But rather than do that, we might just start believing the consumers who are telling us loud and clear that they can’t find wholesale billing GPs and are struggling to pay for primary healthcare. Continuing to shine a light on them by repeatedly trumpeting utterly meaningless mass billing statistics is making our out-of-pocket medical bill crisis worse and must stop.

My doctoral research concluded that Medicare is unfortunately in trouble. It is hemorrhaging to the tune of around $7 billion a year and urgent action is needed to stem the tide.

It’s not too late, but without evidence-based structural reform encompassing regulation, education and digitalization, consumer OOPs will continue to rise.

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