Patients are missing out on subsidised medical appointments for chronic diseases due to incorrect Medicare billing by GPs, prompting the Australian health department to issue hundreds of warnings.
Throughout February compliance letters were sent to 596 healthcare providers who regularly claimed subsidies from the government for developing or reviewing a chronic disease management plan for their patients and, for the same appointment, also claimed a separate subsidy for providing chronic disease management and support services.
The development and review of the chronic disease management plan already includes subsidies for management and support services, making it unnecessary for GPs to claim for this service on top.
Chronic disease patients are entitled to five subsidised appointments a calendar year for chronic disease management and support services on top of their subsidised and more comprehensive appointment for a chronic disease management plan and review. This is to help support them between those major appointments.
If their GP is claiming the support and management service at the same time as their appointment for their chronic disease plan or review, the patient then loses the opportunity to book a separate and additional subsidised appointment.
Subsidies are claimed by GPs under the Medicare benefits schedule (MBS), with each service attached to an item number.
A spokesperson for the health department said wrongful co-billing of item numbers during the same appointment meant “patients may miss out on care, as they may lose the benefit of one or more of the five services they are entitled to”.
No penalty was given to doctors found to be regularly co-claiming support services with chronic disease management plan services, he said, but the letters asked healthcare providers to review their MBS item claims and ensure they were doing the right thing.
The compliance action follows PhD research from a lawyer and nurse, Dr Margaret Faux, who undertook a comprehensive review of Medicare and found illegal or wrongful billing by doctors and other health providers was rampant. Often this wrongful billing was accidental, she found, as the Medicare system was so complex it was hard for doctors to comply.
The compliance letters have angered the Royal Australian College of General Practitioners, which in a statement described the letters as an “unnecessary headache” for GPs.
The RACGP president, Dr Nicole Higgins, said the letters should be withdrawn. “There are circumstances where these item numbers can legitimately be claimed together and many GPs who have done so have done nothing wrong,” she said.
“There is also nothing in the relevant Medicare Benefits Schedule item descriptors to say that they cannot be claimed on the same day. Instead of carefully investigating any unintentional misuse of Medicare items, the department has taken a scatter-gun approach and written an appallingly vague letter to almost 600 GPs who just happen to have co-claimed these items at a higher rate than their peers.
“What the department needs to understand is that GPs service diverse patient populations, and some work in areas with a higher burden of chronic disease than others.”
In response, a health department spokesman told Guardian Australia the department was aware of certain circumstances where the item numbers could be legitimately claimed on the same day but those GPs were not the target of the compliance letters.
He said the department’s integrity division analysed data to “systematically review claims made for Medicare Benefits Schedule items”. He said this data was then “assessed through human analysis, including comprehensive assessment of policy and legislation requirements, consultation with internal medical advisers, operational compliance areas, as well as external health subject matter experts”.
“These reviews allow us to design comprehensive compliance approaches ranging from light touch interventions such as provider education and targeted letters, through to audits and investigations in the small number of cases where providers are intentionally non-compliant,” he said.
Information about potential non-compliance was also received through tipoffs, and from other agencies and stakeholders, and peak medical bodies were consulted in the design of compliance activities, he said.
