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

Abstract

Background Medical billing errors and fraud have been described as one of the last “great unreduced healthcare costs,” with some commentators suggesting measurable average losses from this phenomenon are 7% of total health expenditure. In Australia, it has been estimated that leakage from Medicare caused by non-compliant medical billing may be 10–15% of the scheme’s total cost. Despite a growing body of international research, mostly from the U.S, suggesting that rather than deliberately abusing the health financing systems they operate within, medical practitioners may be struggling to understand complex and highly interpretive medical billing rules, there is a lack of research in this area in Australia. The aim of this study was to address this research gap by examining the experiences of medical practitioners through the first qualitative study undertaken in Australia, which may have relevance in multiple jurisdictions. Method This study interviewed 27 specialist and general medical practitioners who claim Medicare reimbursements in their daily practice. Interviews were recorded, transcribed, and analysed using thematic analysis. Results The qualitative data revealed five themes including inadequate induction, poor legal literacy, absence of reliable advice and support, fear and deference, and unmet opportunities for improvement. Conclusion The qualitative data presented in this study suggest Australian medical practitioners are ill-equipped to manage their Medicare compliance obligations, have low levels of legal literacy and desire education, clarity and certainty around complex billing standards and rules. Non-compliant medical billing under Australia’s Medicare scheme is a nuanced phenomenon that may be far more complex than previously thought and learnings from this study may offer important insights for other countries seeking solutions to the phenomenon of health system leakage. Strategies to address the barriers and deficiencies identified by participants in this study will require a multi-pronged approach. The data suggest that the current punitive system of ensuring compliance by Australian medical practitioners is not fit for purpose.

Audit of surgeon billing in workers compensation‐insured elective spinal surgery in New South Wales, Australia from 2010 to 2018

“…Previous research on medical billing in Australia found system issues, rather than intentional abuse by physicians, to be foundational to noncompliant medical billing. 5 Strengths of this research include a large dataset with populationlevel coverage including over 12 000 spinal surgeries over a 9-year period. Limitations were the use of administrative data which does not include specific details about indication or type of surgery, which prevented assessment of some of the issues identified by the MBS Review Taskforce.…”

“…These items may have been billed appropriately; however we were not able to assess this as the dataset does not include the indication for surgery. Previous research on medical billing in Australia found system issues, rather than intentional abuse by physicians, to be foundational to non‐compliant medical billing 5 …”

“…3 In Australia, compliance with Medicare is considered the responsibility of the practitioner, while the government acknowledges that 'most non-compliance is inadvertent'. 4,5 The Medicare Benefits Schedule (MBS) is a list of medical services subsidized by the Australian Government. 6 In 2015, the Australian Government initiated a comprehensive review of the MBS, including spinal surgery.…”

“…High variability in surgeon billing patterns, which may reflect uncertainty or lack of clarity regarding billing guidelines, has been reported in the United States as early as 1991 3 . In Australia, compliance with Medicare is considered the responsibility of the practitioner, while the government acknowledges that ‘most non‐compliance is inadvertent’ 4,5 …”

Development of billing post competency evaluation index system for nurses in China: a Delphi study

“…However, due to irregular doctor orders, inconsistent expenses and actual time, and poor understanding of pricing policies, billing remains a problem of concern [ 9 ]. Patients doubt their bills, and medical costs are also increasing rapidly [ 5 , 10 ]. In recent years, the National Healthcare Security Administration has increased unannounced inspections, thereby increasing pressure on nurses.…”