18 October 2016

High cost of catching the Medicare crooks

Medicare TheHill


The cost of recovering funds from dodgy Medicare claims by health practitioners appears to be trending higher than the money retrieved.

The Department of Health wrapped up 3,912 audits and reviews of practitioners in the year to June 2016, including 190 fraud investigations which it said were in the “most serious” category and did not reflect honest mistakes.

It sent 35 cases to the Commonwealth Director of Public Prosecutions and 80 to the in-house Professional Services Review (PSR).

The Medicare provider compliance program newly identified recoverable debts of $16.3 million in the year, after seeing a bulge of more than $60 million in 2014-15, according to the department’s annual report tabled this week.

However, it managed to recover debts of only $9.9 million, less than the $12 million a year earmarked for compliance measures over the next four years.

The sum included money paid back by GPs who had been warned earlier in “targeted letters” about claiming for patients who did not have a valid concession card on the date of their consultation but had kept up the practice.

Scrutiny in 2015-16 also focused on specialists’ MBS claims for referred consultations and assisted reproductive technology items, as well as pathology and diagnostic imaging services.

Some 80 doctors were referred to the PSR because of unusual claiming or prescribing patterns, including five who breached the so-called 80-20 rule.

Under the Health Insurance Act, GPs and other health practitioners who supply more than 80 services in 20 days in a single year must be reviewed by the PSR.

The Department of Health took over the role of monitoring Medicare compliance by healthcare providers from the Department of Human Services in November last year.

The program’s headline achievement in 2015-16 was the conviction, also in November, of a GP locum who was jailed for three years for fraudulently obtaining more than $850,000 in Medicare benefits.

A hotline set up in February received about 850 tips from members of the public of healthcare providers about potential non-compliance or fraud in its first five months, the report said.

The ostensibly recoverable amount was identified through audits, acknowledged by practitioners or calculated from penalties and determinations, it said.

The government set aside $48 million over four years in the May budget to enhance the Medicare compliance program and improve the low rates of debt recovery from health providers.

It projected the budget measure would yield savings of $66.2 million, which would be redirected into health funding.

In the preceding three years to June 2015, a DHS-run compliance regime invested $7.6 million in a crackdown aimed at alleged over-servicing by larger medical practices, defined as those with four practitioners or more.

It calculated savings of up to $71.5 million over the three years, almost entirely due to “behaviour change” among doctors in response to a strategy of reviewing all practitioners at practices where over-servicing was suspected.

COVID-19 live update
Something to say?

Leave a Reply

4 Comments on "High cost of catching the Medicare crooks"

Please log in in to leave a comment

Sort by:   newest | oldest | most voted
Dr David Chan
Dr David Chan
3 years 9 months ago
when will it finally sink in that the simplest, cheapest and most cost effective way to recover fraudulent medicare claims is to stop or decrease bulk billing especially universal bulk billing. The consumers (patients) will be the biggest monitor of rebate claims if they have to PAY for doctors’ services especially whether they are needed, of appropriate standards, value for money or actually performed as is normal for every other business. If you add Medicare surveillance, then the amount of Medifraud will disappear virtually overnight. Who cares when something is apparantly for free? Governments are now having to face the… Read more »
3 years 9 months ago

The actual amount recovered vs the cost of recovery is not the point.
Even in a “good’ society, you need to pay Police to maintain law and order, even if no arrests are made.
Similarly, you still need to run RBT even if no one is caught.
BECAUSE, the moment you stop RBT, drink driving will re-start.
Can you imagine a society which disbands the Police Force because too few arrests are made ?

The deterrent factor is significant.
For every one you catch, there will be “n” who did not commit the crime out of fear of being caught.

Dr Lou Lewis
Dr Lou Lewis
3 years 9 months ago
I remember a time, about 25 years ago, the government of the day alleged that Medicare fraud to be about $100 million a year , but, because of its opposition to bulk billing, the AMA at the time wanted to score political points and said it estimated the fraud to be closer to $200 million, and after that every time the word ‚Äò medical‚Äô fraud was mentioned the government would quote the AMA’s figures of $200 million dollars as being a fact, not just a made up figure. Over the years the amount of fraud has been minuscule compared to… Read more »
Dr David Chan
Dr David Chan
3 years 9 months ago
Lou – anyone can defraud Medicare they way bulk billing is set up. Who checks the service delivered when claims can be made by the doctor / reception staff / whoever and no money changes hand? Amazingly, the introduction of a small co-payment ($3.50) would have stopped this rort and dismantle the legislation forbidding to charge any co-payment when bulk billing. It was handed to us on a platter, yet our smart leaders, doctors and Organisations turned it down and were more interested in political spin rather than serious medical business / quality of Medicine discussion and reform.