Under or over? General practitioner charging of Medicare

Abstract

Background and objectiveIn 2022, media reports alleged that doctors, particularly general practitioners (GPs), are defrauding Medicare, claiming $8 billion lost through fraud/noncompliance. This study examined Medicare Benefits Schedule billing patterns by consultation length to estimate overcharging or undercharging by GPs, and the cost/savings to Medicare. MethodsA subset of data from the Bettering the Evaluation And Care of Health (BEACH) program from 2013 to 2016, which included length of consultation information, was analysed. ResultsOf 89,765 consultations, GPs undercharged 11.8% of consultations and overcharged 1.6%. Of the 2760 GPs sampled, 816 (29.6%) overcharged at least once and 2334 (84.6%) undercharged at least once. Of the GPs who overcharged at least once, 85.4% also undercharged. The total effect of GP undercharging and overcharging was a net saving of $351.7 million to Medicare. DiscussionThis study shows that GPs undercharging and overcharging saved Medicare over one-third of a billion dollars in 2021-22. The findings of this study do not support the media claims of widespread fraud by GPs.AUSTRALIA has a universal fee-for-service health insurance scheme called Medicare, through which the Australian Government subsidises or pays in full for communitybased medical services, including visits to general practitioners (GPs). 1 Australians collectively have more than 180 million consultations with GPs every year, with 90% of the population claiming for a GP visit at least once in 2021-22. 2 In 2021-22, a total of $28.8 billion was paid in Medicare benefits, with claims for GP services accounting for $9.1 billion. 2 The Medicare Benefits Schedule (MBS) is a listing of the services subsidised through Medicare. One part of the Schedule includes items for professional attendances by a GP, and the levels (A-D) applicable to these items, to assist GPs in selecting the appropriate fee (known as the 'scheduled fee') when charging. 3 GPs can charge for one or more MBS items for a patient encounter, including those that relate to the type of attendance (e.g. surgery, home visit) and its length, identified according to four groups (Levels A-D; see Box 1).In October 2022, media reports alleged doctors (and GPs in particular) are defrauding Medicare, with claims that $8 billion (27.8% of the total benefits claimed in 2021-22) is lost through fraud, non-compliance and overservicing. 4,5 These claims were reportedly based on a PhD thesis; however, the thesis does not mention this $8 billion figure, nor does it include any quantitative data that would support this claim. 6 The thesis states:Under or over? General practitioner charging of MedicareUnder or over? General practitioner charging of Medicare Research