An audit of after-hours MBS item claims has resulted in substantial paybacks to Medicare and there could be more to come
One doctor has been ordered to repay Medicare $200,000 and subjected to practice curbs as part of a crackdown on the use of after-hours MBS item numbers.
The practitioner was found to have misused MBS item 5040, as well as non-after-hours items. The penalty included a three-month disqualification from claiming item 5040, used for long after-hours consultations in a clinical setting.
 Two other doctors acknowledged they had improperly claimed a range of after-hours items and were ordered to repay sums of $100,000 and $95,000, respectively. Â
The three cases were among 16 referred to the Professional Services Review for investigation of allegedly irregular after-hours billing in the 2016-17 financial year ended in June, the Department of Health revealed. Â
Some incorrect claims came to light through audits of after-hours activity, while others were volunteered by after-hours providers amid increased scrutiny following a surge in after-hours claims. Â
“A number of after-hours service providers have contacted the Department of Health to voluntarily acknowledge incorrect claiming,” the department said. Â
Of the 16 cases, 11 are still awaiting a decision by the review. One case has been referred to the Medical Board of Australia over the sudden closure of a practice without notice. Â
The information was disclosed in answers to questions on notice lodged in May by South Australian Senator Stirling Griff of the Nick Xenophon Team. Â
In the 2015-16 financial year, and so far in the year to date, there was insufficient evidence to warrant any referrals for fraud over after-hours claims, the department said.
The department also said there was no evidence that the rapid growth in billings for “urgent” after-hours home visits had eased pressure on hospital emergency departments.
“Data held by the Department of Health does not support the argument that emergency department presentations have reduced in areas where the billing of Medicare Benefits Schedule urgent after-hours services has significantly increased,” it said.
“Furthermore, the department does not believe it is appropriate to draw comparisons between the use of EDs and MBS urgent after-hours items” because of the very different levels of care offered.
Rather, data suggested many patients were substituting urgent after-hours home visits for routine general practice visits, it said.
But the department also said it had no proof that people were receiving a lower quality of care as a result.
“The model of care offered by a medical deputising service differs from that of a general practice, making it difficult to directly compare quality of care,” it said in reply to a question from Greens Leader Senator Richard Di Natale.
“The department is not aware of any data which explores this issue.”
In draft recommendations, the MBS Review Taskforce has called for confining the use of urgent after-hours item numbers to registered GPs.
In other words, a non-GP deputising service would lose the right to claim a premium, slashing the call-out fee from $130 from the most commonly used urgent item 597 to the standard rate of $75.
Urgent items 597 and 599 cost Medicare $246 million in 2015-16, having surged 150% in five years. In the year to June 2017, after an outcry by doctors, the outlay slipped back to $220 million.
Last weekend, however, Queensland Health Minister Cameron Dick called on the federal government to drop any plans to curtail after-hours home doctor services.
Mr Dick said the Queensland Ambulance Service was being swamped by a serious influenza outbreak concentrated in the state’s southeast.
In the past two weeks, the Queensland Ambulance Service has experienced eight of its 10 busiest days for Code 1 call-outs in its entire history, with high numbers of flu patients critically ill with cardiac and respiratory trouble.
“Any cuts to the Medicare rebate for the home doctor service would be a disaster for our state’s public hospitals and ambulance service,” Mr Dick said.
The minister was alarmed by media reports claiming federal government plans to halve the rebate for home visits would cause the collapse of home doctor services.
The largest medical deputiser, National Home Doctor Service, has said the loss of the urgent premium would likely make many services unviable.
A survey of 314 GPs commissioned by the group had found they would be unwilling to make up the shortfall, NHDS said.
