No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?

Abstract

The complexity of Medicare claiming means it is often beyond the comprehension of many, including medical practitioners who are required to interpret and apply Medicare every day. A single Medicare service can be the subject of 30 different payment rates, multiple claiming methods and a myriad of rules, with severe penalties for non-compliance, yet the administrative infrastructure and specialised human resourcing of Medicare may have decreased over time. As a result, medical practitioners experience difficulties accessing reliable information and support concerning their claiming and compliance obligations. Some commentators overlook the complexity of Medicare and suggest that deliberate misuse of the system by medical practitioners is a significant contributor to rising healthcare costs, although there is currently no empirical evidence to support this view. Quantifying the precise amount of leakage caused by inappropriate claiming has proven an impossible task, although current estimates are $1-3 billion annually. The current government's proposed copayment plan may cause increases in non-compliance and incorrect Medicare claiming, and a causal link has been demonstrated between medical practitioner access to Medicare education and significant costs savings. Medicare claiming is a component of almost every medical interaction in Australia, yet most education in this area currently occurs on an ad hoc basis. Research examining medical practitioner experiences and understanding regarding Medicare claiming and compliance is urgently required to adapt medicine responsibly to our rapidly changing healthcare environment.

Who teaches medical billing? A national cross-sectional survey of Australian medical education stakeholders

“…6 Others may be unaware of the myriad legal obligations applicable to each claim, particularly when a single medical service in Australia can be the subject of more than 30 payment rates, multiple rules and strict penalties for non-compliance. 7 …”

“…1 4 10 11 It has also been identified as an issue in Australia, 12 23 where the medical billing system is divorced from clinical designations (such as the ICD) and a single medical service can be the subject of over 30 different fees, rules and penalties. 7 There have been suggestions that education may improve billing literacy, 9 yet there has been scant research attention on training medical practitioners regarding correct medical billing. In response to the dearth of research in this area, this study attempts to systematically map all avenues of medical practitioner education on Medicare billing and compliance in Australia and explores the perceptions of medical education stakeholders on the teaching of medical billing in Australia to inform appropriate policy and regulatory initiatives.…”

Educational Needs of Medical Practitioners About Medical Billing: A Scoping Review of the Literature

“…However, this is and was always an unrealistic and onerous requirement on medical practitioners given the current printed version of the MBS comprises over 900 A4 pages of item numbers, explanatory notes, rules and cross references, many of which are difficult to comprehend, and a single medical service can be the subject of over 30 different payment rates and rules. 26 We also found no evidence of medical billing educational resources such as a 25 year body of precedent that might assist medical practitioners to understand how to bill correctly.…”

“…This practice is evident in the current out-of-pocket medical fees crisis in Australia. 26 Another serious and potentially dangerous impact is that working under the constant threat of audits and investigation may cause some medical practitioners to under-service their patients.…”

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing

“…14-16 This finding also aligns analysis of Australian medical billing policies which reported that a single Medicare service in Australia can be the subject of more than 30 different payment rates, multiple claiming methods and myriad rules. 17…”