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

Faux, Margaret; Adams, Jon; Dahiya, Simran; Wardle, Jon

doi:10.1101/2020.05.26.20113324

Cited by 3 publications

(2 citation statements)

References 11 publications

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“…Others may continue to provide services but not bill and be reimbursed for them, reducing government visibility over actual service delivery. A recent study in Australia described evidence of such practices among medical practitioners [28].…”

Section: Discussionmentioning

confidence: 99%

Educational needs of medical practitioners about medical billing: a scoping review of the literature

2021

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Introduction The World Health Organization has suggested the solution to health system waste caused by incorrect billing and fraud is policing and prosecution. However, a growing body of evidence suggests leakage may not always be fraudulent or corrupt, with researchers suggesting medical practitioners may sometimes struggle to understand increasingly complex legal requirements around health financing and billing transactions, which may be improved through education. To explore this phenomenon further, we undertook a scoping review of the literature to identify the medical billing education needs of medical practitioners and whether those needs are being met. Methods Eligible records included English language materials published between 1 January 2000 and 4 May 2020. Searches were conducted on MEDLINE, PubMed, Google Scholar, CINAHL, LexisNexis and Heinonline. Results We identified 74 records as directly relevant to the search criteria. Despite undertaking a comprehensive, English language search, with no country restrictions, studies meeting the inclusion criteria were limited to three countries (Australia, Canada, US), indicating a need for further work internationally. The literature suggests the education needs of medical practitioners in relation to medical billing compliance are not being met and medical practitioners desire more education on this topic. Evidence suggests education may be effective in improving medical billing compliance and reducing waste in health systems. There is broad agreement amongst medical education stakeholders in multiple jurisdictions that medical billing should be viewed as a core competency of medical education, though there is an apparent inertia to include this competency in medical education curricula. Penalties for non-compliant medical billing are serious and medical practitioners are at risk of random audits and investigations for breaches of sometimes incomprehensible, and highly interpretive regulations they may never have been taught. Conclusion Despite acknowledged significance of waste in health systems due to poor practitioner knowledge of billing practices, there has been very little research to date on education interventions to improve health system efficiency at a practitioner level.

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Section: Discussionmentioning

confidence: 99%

Educational needs of medical practitioners about medical billing: a scoping review of the literature

2021

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“…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?…”

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Under or over? General practitioner charging of Medicare

Harrison¹,

Gordon²,

Henderson³

et al. 2023

Aust J Gen Pract

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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

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

Faux

Adams

Wardle

2021

Preprint

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IntroductionThe WHO has suggested the solution to leakage in health systems caused by waste, corruption and fraud is policing and prosecution. However, a growing body of evidence suggests leakage may not always be fraudulent or corrupt, with researchers suggesting medical practitioners may sometimes struggle to understand increasingly complex legal requirements around health financing and billing transactions, which may be improved through education. To explore this phenomenon further, we undertook a systematic review of the literature to identify the medical billing education needs of medical practitioners and whether those needs are being met.MethodsEligible records included English language materials published between 1 January 2000 and 4 May 2020, including empirical research, commentary, opinions and grey literature.ResultsWe identified 74 records as directly relevant to the search criteria. Despite a comprehensive international search, studies were limited to three countries (Australia, Canada, U.S), indicating a need for further work internationally. The literature suggests the education needs of medical practitioners in relation to medical billing compliance are not being met and medical practitioners desire more education on this topic. Evidence suggests education may be effective in improving medical billing compliance and reducing waste in health systems and there is broad agreement amongst medical education stakeholders in multiple jurisdictions that medical billing should be viewed as a core competency of medical education, though there is an apparent inertia to act. Penalties for non-compliant medical billing are serious and medical practitioners are at risk of random audits and investigations for breaches of sometimes incomprehensible, and highly interpretive regulations they may never have been taught.ConclusionDespite acknowledged significance of leakage in health systems due to poor practitioner knowledge of billing practices, there has been very little research to date on education interventions to improve health system efficiency at a practitioner level.

show abstract

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

Cited by 3 publications

References 11 publications

Educational needs of medical practitioners about medical billing: a scoping review of the literature

Educational needs of medical practitioners about medical billing: a scoping review of the literature

Under or over? General practitioner charging of Medicare

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

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