Poor documentation and cavalier prescribing were far more likely than fraud to attract the notice of the Medicare watchdog in 2021-22.
In the past financial year, Medicare’s investigative arm referred just three practitioners to regulators due to suspected fraud, despite recent media claims that doctors were rorting Medicare to the tune of billions of dollars a year.
In its 2021-22 annual report, released last week, the Professional Services Review (PSR) said fraud was a concern in “only a small number of cases”.
The previous year, just one case was referred by the PSR for suspected fraud.
While the figures show it’s not rorters who end up before a PSR committee, it sheds no light on the trauma and the professional price paid by doctors who are investigated by the Medicare body.
During 2021-22, the PSR received 108 requests from the chief executive of Medicare – up from 73 in the previous year – to look into possible cases of inappropriate billing.
Of those, 22 practitioners were referred to AHPRA or the medical boards due to concerns about patient safety or non-compliance with professional standards, while just three practitioners were referred back to the Medicare chief executive, or to a regulatory authority, due to suspected fraud.
“Key concerns were billing deceased patients, non-contemporaneous notes and billing for surgical procedures where there was no consent or other paperwork to support the billed procedure had occurred,” the report said.
“However, fraud was a concern in only a small number of cases.
“The major concerns identified related to lack of clinical input and extremely poor documentation. When practitioners are very busy, documentation in records can become poor and this can risk patient safety.”
This reflects the concerns of many critics of the past fortnight’s media reports who say while inappropriate billing is clearly a problem, it’s more likely due to the complexity of the Medicare system and a lack of understanding of how services should be billed rather than criminal activity.
Common items reviewed by the PSR in their investigation of GPs were level B, C and D consultations (MBS Items 23, 36 and 44) and chronic disease management items (MBS items 721, 723 and 732) and their equivalent telephone consultation items although the equivalent video consultation items did not feature as a concern.
The PSR also reviewed health assessments, ordering of pathology and radiology, and prescribing.
When it came to prescribing, the PSR said there was a “concerning trend” of inadequate clinical input around the issue of some prescriptions.
“The emergence of ‘scripts on demand’ services was noted to be associated with poor medical history, no examination, no investigation, and no documentation of discussion of overall safe patient management,” the report said.
“Sometimes expensive medications with strict authority restrictions were prescribed with absent or minimal clinical input.”
The PSR said it had also found that prescribers were sometimes not following the rules for the prescription of some expensive and heavily-subsidised PBS medicines.
The agency warned that practitioners need to balance their workload to ensure they leave sufficient time to ensure the documentation in patient records remains accurate and able to safely ensure continuity of care.
However, this will come as no comfort to healthcare professionals – and especially to GPs – who argue that increasing amounts of paperwork to remain compliant are getting in the way of providing quality care to patients.
“The reliance on electronic autofill in some entries may also aggravate the risk of poor documentation that does not reflect the content of a consultation,” the report said.
While the PSR received $11,987,000 from the government in the past financial year, just $19,021,883 was recovered in Medicare repayments from negotiated agreements and final determinations.
The PSR increased its staff from 27 to 30, with former director Professor Julie Quinlivan netting a base salary of $349, 627.
Meanwhile, a bill that would expand the powers of the PSR to investigate and take action against corporates and non-clinicians passed the Senate yesterday and will now be introduced into the House of Representatives.
The committee that reviewed the bill before its introduction earlier this year said while it was generally supported, the bill still “raised some broader issues about the complexity of the Medicare system, compliance burdens for practitioners and the adequacy of support to achieve compliance”.
