Australian health practitioners ordered to pay $4 million for wrong Medicare claims

Doctors have been ordered to pay back $4.17 million for incorrect claims as they exploited the ambiguities in the Medicare Benefits Schedule, or MBS, a report has revealed.

According to the 2014-15 report by the Australian government’s independent Professional Services Review, or PSR, referrals for investigations increased by 40 percent in the last financial year. Serious concerns have been raised to the PSR about the misuse of taxpayer-funded chronic disease management plans by doctor for personal financial gain.

Of the matters referred for investigation, 70 percent resulted in further action being taken. In addition to the repayment of Medicare benefits, reprimands and restrictions on health practitioners being able to access Medicare benefits in the future have also been ordered.

The PSR is made up of independent committees of respected medical professionals who peer review serious allegations of Medicare non-compliance against health practitioners that are detected by the Department of Human Services.

Since the Chronic Disease Management items were introduced nine years ago, the government has seen 22 million Medicare claims at a cost of $2.7 billion, according to Minister for Health Sussan Ley. “This is significant when you consider the number of Medicare items claimed have now reached an average of one million per day,” she said.

Ley expressed her concerns about the “grey areas” and ambiguities in the rules, which make it harder to track and prove non-compliance. These referrals to the PSR may be just the “tip of the iceberg”, Ley noted. As the report acknowledges, a big part of the problem is the compliance system governing Medicare is 20-to-30 years old, she said. Given this, Ley expressed that she wants to work with health professionals to update it to reflect 21st century medical practices.

The Australian government is pushing its plans for a wide-ranging review of all 5,700 items on the MBS, and the rules governing their use to ensure they reflect contemporary clinical practice for doctors and their patients and are not misused. “These findings show the importance of having clear, strong rules around the use of individual Medicare items to ensure they are clinically relevant and reflect contemporary practice, but also aren’t misused for financial gain,” Ley said.

In addition, there will be a review of primary care service delivery, and funding, models, particularly around chronic disease and whether fee-for-service remains the most-appropriate model. The government also seeks to strengthen the compliance and education around the use of Medicare items by health practitioners and practices.

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