How broken is Medicare if doctors need a course to understand it?

4 minute read

It’s been a week of outrage in Surgery Land. You can blame the media, or you can blame an over-complex Medicare billing system that invites abuse.

Last Monday’s episode of Four Corners spewed out so much bile that it’s not easy to wade through in search of the important bits.

For those who haven’t been keeping track, Four Corners used a bunch of billing data from spinal fusion patients, given to them by six Australian health insurance companies, and came up with evidence of item number misuse by anaesthetists and surgeons. You can read our coverage here.  

Then followed a familiar pattern of outrage on social media from practitioners, particularly anaesthetists, backed up by GPs, who copped a similar shellacking from the ABC from October 2022 through to April 2023, when Dr Pradeep Philip’s review debunked the more extreme claims.

There has been a lot of back and forth about the Medicare system, including the news that the Leo Cussen Centre for Law is offering an “Australian-first” course on Medicare billing and practice.

First of all, let’s not pretend that there isn’t billing fraud going on, or that it’s something new we’ve just discovered. 

Back in May 2019 – yes, that pre-covid era that seems another universe away – Professor Bruce Robinson, then chair of the MBS review taskforce, and his taskforce deputy chair Professor Steve Hambleton, former federal president of the AMA, had plenty to say about this at a conference covered by HSD’s sister publication, The Medical Republic.

At the time Professor Robinson estimated 5-10% of doctors were not acting in good faith. That sounds familiar.

“People who are ripping off the system are going to spoil it for everyone,” he said.

He did concede that misinterpretation of the MBS was not always intentional. As an example, he spoke of a cardiac surgeon who always billed for a thoracotomy and chest drainage as well as the cardiac surgery, as that was what he had thought all cardiac surgeons did. These procedures were assumed, but not specifically listed, in the cardiac surgery MBS item number.

Often the descriptors for item numbers were very poor, providing opportunities for gaming the system, he said.

Margaret Faux denies conflict of interest

Surgeons, anaesthetists outraged by fraud accusations, and insurers’ actions

Professor Robinson said this first ever MBS review, which involved more than 5700 MBS item numbers, had been much more complex than originally anticipated, taking more than twice as long as the anticipated two years.

And – shock, horror – Professor Robinson described the rebate for delivering an anaesthetic for a straightforward colonoscopy which took minutes was very similar to that for giving an anaesthetic for an hours-long cancer operation.

That comment led to a call from the Australian Society of Anaesthetists for his resignation, suggesting he didn’t understand the complexities of how rebates worked for their profession and suffered from a “Robin Hood complex”.

This week, the ASA was a little more guarded in its response to the latest fraud allegations.

“Some of the broad-brush claims made, not by the impacted patients, were inflammatory and try to bring into disrepute the work done by anaesthetists around Australia on a daily basis,” the Society said in a statement.

“This highlights the importance of seeking input from bodies such as the ASA, where there are concerns, before going public with incomplete and potentially inaccurate information.

“For example, the quote of 87% of anaesthetists overstating time appears to be based on a gross misinterpretation of the Medicare items claimed for anaesthesia. The vast majority of the anaesthesia time claims are likely to be correct.”

Professor Robinson’s comment back in 2019 about the complexity of the MBS item number system, brings me back to the Leo Cussen course on Medicare billing and practice.

As Dr Mariam Tokhi said on Twitter on Wednesday, why does it need to be this complicated?

Amen to that. How broken is Medicare if doctors need a course to understand it?

The more complex a system is, the more amenable it is to unconscious errors, and very conscious fraud.

Time for change.

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