Doctors untrained in Medicare billing

Medical politics

By Tessa Hoffman

24 Jul 2018

New research has exposed a glaring hole in the Medicare billing system, revealing most doctors receive no formal training in how to bill correctly and yet can face criminal charges for errors.

Just 30 % of medical education providers offer any training in how to bill through Medicare, according to a survey of 57 Australian providers. The list of education bodies includes specialist colleges, university medical schools, GP vocational training providers, medical defence organisations, state AMA branches and two government agencies.

The cross-sectional survey – performed between 2014 and 2015 – shows that more than two thirds of the providers offering Medicare training are GP vocational training organisations. In contrast, specialists “appear to receive almost no training in this area”, with only two specialist colleges found to be offering basic training which was of under two hours duration, on a voluntary basis and with no assessment.

This is significant “given most specialists engage in hospital-based medical billing which in Australia has profound complexity”, according to study lead author Margaret Faux, CEO of medical administration company Synapse and a PhD candidate at the University of Technology in Sydney (UTS).

“The average course length of less than two hours is unlikely to achieve the high level of legal and administrative literacy that is expected of medical practitioners working within a complex system of nearly 6000 reimbursement items, over 900 A4 pages of service descriptions, complex cross-referencing administrative permutations and rules,” she writes with co-authors in BMJ Open.

Yet this Medicare know-how is critical for doctors given they can be investigated for billing incorrectly in both civil and criminal jurisdictions, the article notes. Doctors under investigation “will often state that they did not know the conduct for which they stand accused was wrong”, the article observes.

The defence of ignorance has proved unsuccessful in preventing convictions for Medicare claiming irregularities in the past, but the authors say their study suggests “there may sometimes be veracity in such submissions” given most Australian doctors were never taught how to bill.

In cases where doctors were found to have breached Medicare billing requirements,  one government agency said it would refer them to Medicare for further learning, while the other did not.

Ms Faux tells the limbic she is about to complete a postgraduate research project that investigates Medicare claiming and compliance from the perspective of medical practitioners, and which has involved extensive interviews with doctors.

“Most doctors would like to do the right thing by Medicare if only they knew what that was, but it’s impossible to find out,” she says.

“They are thrown under a bus into this very complex legal system when they graduate from medical school with no training at all and then they’re accused of rorting.”

“Quite commonly they will work in on their first day on the job and a practice manager will say to them ‘here’s a laminated piece of plastic if you see someone for five minutes use that item, if you see someone for 20 minutes use that item. Away you go.’

“And quite literally that is the extent of their training. For a specialist it’s even less.  In interviews they are saying ‘there was nothing….I asked a colleague’ That is how they are learning to do it around the country.”

In her study, medical training providers broadly agreed that doctors should be formally trained in how to bill Medicare, but there was no consensus over when or who should deliver the training.

Medicare was often suggested as a potential training provider by survey participants, but the authors say this would pose conflict of interest and legal challenges.

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