2 November 2021

How to get noticed by Medicare

Comment KnowCents Medicare

When we first got our high school transcripts and planned our future as healthcare professionals, I don’t think any of us realised the extent to which we were condemning ourselves to a life of accountability to the Australian taxpayer. 

Both from a regulatory, registration point of view (AHPRA) and from a billing point of view (Medicare, for those of us relying on this as an income source or rebate for our patients), our actual line manager for the entirety of our professional life is basically the Commonwealth.

The problem perhaps stems from the fact that few, if any, education or practice modules are compulsory or even exist within the university degrees that we so wholeheartedly work on. 

We never knew, for one thing, that on top of the clinical jargon we need to know and be experts in, we also needed to be pseudo legal and financial experts to survive in our careers and  to avoid the potential devastations that are currently supported by law in this country. 

I have great empathy especially for those who have migrated to Australia, many who were regarded as very high-profile clinicians in their own home country. They work so hard to establish themselves in accordance to the laws of this country, and then get subjected to these onerous and often “unfair” audit processes. In the absence of a formal, legislatively endorsed education system where all Medicare-billing clinicians must learn and get certified in the areas of billing, these interrogations and audits are scary indeed. 

A few of the most common replies I get when I have dinner with colleagues, when the topic of Medicare audit arises, are:

  • Well, I have been practising for so many years and I have had no problems so it must be applicable for those that are basically outliers or are bad people.
  • People that get pinged or fined by Medicare are those who are international medical graduates or naive registrars such as Anchita, who really did not know how to bill or have good medical records – won’t happen to me as I am very good at what I do.
  • Greedy people are the only ones that get pinged by the system. Seriously, stop being greedy, belligerent and justifying your conduct by fighting a good system.
  • The PSR and Medicare have peers and colleagues who are experts in telling you if they think you have done something wrong, so surely if they say you are wrong, you must be wrong.
  • I privately bill only, or I bill only a very little amount so surely Medicare will not notice me and I have nothing to worry about.
  • I am a hospital doctor – yeah, I do bill for my private OPD sessions but that’s the organisation’s responsibility, not mine, so who cares? 

Those seem to be the top six responses – at which point I simply direct them to AHPAS (Australian Health Practitioners Advisory Solutions) for further information if they wish and abort my efforts to convince people that all those points are simply MYTHS. They are just simply not true, and the quicker people realise this, the quicker we can possibly work towards changing this situation of impending doom. 

How exactly do healthcare professionals get noticed by Medicare and or PSR?

Future pieces will talk about the detailed process of PSR, but for now, let’s just grasp this one fact: the PSR on its own cannot initiate any investigations. It can commence an investigation if and only if a practitioner is referred by Medicare.

AHPRA investigates on behalf of the Medical Board/public. The board ultimately is whom we are all answerable to. Just like that, PSR investigates us, and makes their determinations and recommendations to Medicare. Then Medicare are the ones who will ask for the payback, negotiate further and put restrictions in place. 

It is important to understand this in terms of audits, because if we can nip the at the stage of Medicare’s concerns, and not get onto the wagon of PSR investigations, life would be a lot easier to deal with. 

There are two primary ways one can be noticed:

  1. If someone is concerned and has a lot of time on their hands, with a bit of “motivation” they can simply dob you in: Medicare has these websites where you can tip off and dob in your unwanted colleagues (please don’t, obviously). As you can see, it is ever so very easy for anyone who has “concerns” regarding a practitioner’s billing to notify the department and remain anonymous. Nothing other than good conscience deters people from vexatiously and frivolously dobbing people in to Medicare. I have seen first-hand examples of people who have screen-shot their peer’s billing patterns, taken time to redact the medical records, and dob in their competitors and/or “annoying” clinicians to Medicare.

Of course, there are also others who genuinely are concerned about someone’s billing and have used this notification platform. In fact, an interesting comment was made by one of our colleagues who is going through the PSR system, who said: “If I get pinged by a ridiculous penalty, I am going to sit every day in front of my computer and dob in every single colleague I know who bills Medicare, because if I am wrong then I can guarantee they are wrong.”

I do sympathise with this person but yes, it is very tempting … NOT!

  1. Statistical outliers, or as I like to call it, “statistical innovators”: Yes, those who have a special interest in certain things and tend to bill certain item numbers more than  others will more often than not be pinged eventually. It’s literally like an orange flashlight that blinks on the Medicare screen that indicates a practitioner is an “outlier” either by the number of same item numbers being billed or very high billing, regardless of whether you have chosen to work 17 hours a day to actually legitimately bill a person or not.

    The general and unspoken rule is that as Medicare-billing practitioners, you must bill modestly and try to stay within the norm of your profession. If not, you will be noticed, as there is currently no such thing as “statistical profiling” when it comes to categorising someone for their billing patterns and where they sit on the bell curve. It doesn’t matter that you work in a skin cancer clinic or an after-hours clinic where all you do is skin cancer or after-hours billing. You are a statistical outlier for purposes of billing, as those factors are not taken into consideration, and therefore you will draw attention from the regulators. 

Is there any bullet-proof way of making sure you are never noticed by Medicare? Yes.

Don’t bill Medicare. Or wait until clever people make amendments to the legislation and then start billing Medicare.

Food for thought: there is nothing stopping a generally registered doctor or other clinician to charge a purely private fee (no Medicare rebate bulk-billed or claimed direct to Medicare by patients). If you are not getting the assigned Medicare benefit that your patient is entitled to, in any shape or form, Medicare will not be knocking on your door, and nor would PSR. 

Motivations can be vexatious and or genuine. However, I would like to leave you with a thought. Wouldn’t we rather be in a society where we can simply pick up the phone or send an email to the practice/practitioner, stating our genuine concerns and maybe help rectify and better our peer’s conduct before we throw them to the wolves?

Medicare has a statutory (legal) obligation to inquire and investigate each complaint and or concerns. It is never ignored, and it puts each one of our peers, regardless of culpability, through an onerous amount of stress, anxiety and financial burden, plus time away from family and time away from patients. 

I just hope that perhaps we can stop this unhealthy cycle of eating up one another, and work in a collegial and supportive manner rather than fostering a punitive culture.

Dr Anchita Karmakar is the founder and CEO of AHPAS (Australian Health Professionals Advisory Service) and a medicolegal liaison officer at Work Legal

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