When I explained to the GPs that bulk billing for the insertion of an IUD and charging $150 individually for a similar service was illegal, they were horrified. It had been their business model for years. Then once I explained to a patient that his GP had spent greater than 20 minutes undertaking complex work, he was equally horrified, but for various reasons – the GP had apparently taken lower than five minutes to jot down a prescription and order a blood test. That was last week.
I even have been administering medical bills since Medicare began in 1984. The place where I work is best described as Medicare’s underbelly. It’s a dark and disturbingly secret a part of the health system where patient journeys, treatments and procedures are converted to claims for payment. I mainly shuffle the cash across the health system, in an environment where nobody trusts anyone, and consumers are only plain confused and bewildered.
Even before I commenced a PhD on Medicare claiming and compliance in 2012, it was obvious to me that Australian health regulation had change into an omnishambles, and bulk billing was broken.
When the federal government declares that 90% of Australians should not paying out-of-pocket costs on the GP, I’m certain that the majority consumers can be scratching their heads wondering where all the majority billing GPs are hiding.
GP bulk-billing statistics are a crucial metric in measuring the health of our health system, which is why the federal government steadily holds them up as proof that Medicare is in fine condition.
Nevertheless, high rates of bulk billing don’t necessarily indicate that Medicare is functioning well, and throughout the statistics are many complex, and poorly understood phenomena.
Firstly, the GP statistics count services moderately than patients, and patients can have multiple service at one GP visit. When a GP provides multiple service, they wouldn’t have to bulk bill each, and might selected which service is charged. A typical example is bulk billing a consultation, and charging a non-public fee to remove a skin lesion. There is no such thing as a illegality, but the sort of mixed billing skews the information since the bulk billed consultation drops into the statistics, however the procedure doesn’t. So, this patient will fall throughout the 90% group, regardless that they paid on the day. A study undertaken by the RACGP in 2016 suggests this phenomenon reduces the statistics to below 69%. However it doesn’t end there.
There’s also what I might describe as ethically questionable billing, brought on by system dysfunction. Probably the most common example is repeatedly returning patients for added appointments, with the only purpose of enabling more bulk billing. An example could be a patient presenting for a pap smear, back pain, and needing a repeat prescription. All of this might, and may, be handled at one appointment, but when the GP brings the patient back multiple times, their revenue increases.
Then we come to non-compliant billing, which is a spectrum of behaviours with criminal fraud at one end and unintentional errors at the opposite. Probably the most common sort of fraud in Australia occurs when a health care provider knowingly bulk bills for a service they didn’t provide. It’s devilishly difficult to seek out and subsequently prosecute. Moving along the spectrum of illegality, away from fraud, we have now what known as “up-coding”, where a health care provider bills for an extended or more complex service than that provided. That’s what the patient I previously mentioned experienced – a five-minute seek the advice of bulk billed as having taken greater than 20 minutes.
Moving still further along we at the moment are in non-compliant, but not fraudulent territory. An excellent example is present in this 2020 defamation case between two GPs. It’s a sobering examine GPs teaching their colleagues to bill incorrectly to maximise Medicare revenue. One in all the GPs within the case described teaching her GP colleagues to “pack and stack” as many Medicare items as possible onto every patient.
Medicare only reimburses services that patients need, so even when all services are provided, “packing and stacking” unnecessary services is non-compliant.
All of those non-compliant behaviours find yourself in the majority billing statistics. They artificially inflate our health expenditure, and are signs of system failure, not success.
The ultimate, major problem, that skews the information, is bulk billing and charging gaps as separate Eftpos transactions. Once upon a time GPs were charged with criminal fraud for doing this, but an ill-conceived policy change a few years ago has modified all that, and the practice has now change into so common that it is sort of a co-payment by stealth, that’s hidden in plain sight.
As to the impact of this phenomenon on the bulk-billing statistics, well it’s actually very easy to quantify if we wish to. But moderately than do this, we could just start believing consumers who’re telling us loud and clear that they can not find bulk-billing GPs, and are struggling to pay for primary health care. Continuing to gaslight them by repeatedly trumpeting completely meaningless bulk billing statistics is worsening our out-of-pocket medical cost crisis and wishes to stop.
My doctoral research concluded that Medicare is unfortunately in trouble. It’s haemorrhaging to the tune of about $7bn each year and urgent motion is required to stem the flow.
It shouldn’t be too late, but without evidence-based, structural reform encompassing regulation, education, and digitisation, consumer OOPs will proceed to rise.
Dr Margaret Faux is a solicitor and medical insurance law academic who recently published her PhD on Medicare claiming and compliance
