Lacking good advice on Medicare billing, specialists ‘just make it up’


By Michael Woodhead

24 Jan 2022

Specialists are ill-equipped to manage their Medicare compliance obligations and may end up being punished for inadvertent billing errors because they lack access to accurate advice, new research shows.

A review of specialist practitioner knowledge and practices in Medicare billing has found that most are ‘flying blind’, having received no training and they struggle to obtain authoritative advice on appropriate practices.

The qualitative review, led by Dr Margaret Faux, who has just completed a PhD thesis on Medicare claiming and compliance, outlines findings from in-depth interviews with 27 specialists and GPs on their Medicare billing in daily practice.

One key finding was that most specialists had received little or no induction or training around medical billing.

“When you are a Registrar and when you finish you then realise:  ‘Oh, there is Medicare.  Now what have I been taught about Medicare?  Essentially nothing …’ you realise you are supposed to bill,  but still have no inkling how to do it,” said one Salaried Medical Officer interviewed by the researchers.

Dr Faux, who is the CEO of a medical billing consultancy, said the interviews revealed a lack of ‘Medicare literacy’ among specialists, many of whom did not have a basic knowledge of the legal requirements around fundamental practices such as bulk billing and charging a gap fee.

And while doctors wanted to do the right thing regarding Medicare billing, the study showed there was an absence of reliable advice and support around billing, even from Medicare.

One specialist described his frustration on ringing Medicare to try get the correct billing information on MBS item 116, only to be told to look it up in the book.

“I said: ‘I looked at the MBS schedule, I can’t find the answers and I have asked my colleagues what they do and half of them do what I do and half of them put 110’ … I never got the right answer.”

“They said they cannot provide any answers.  It’s pretty poor.  I think there are answers that sometimes,  you know,  you’re not quite sure,  but don’t really know who to ask except for your colleagues and sometimes I feel like the colleagues probably just make it up.”

Dr Faux said the findings showed that non-compliant medical billing in Australia was a mostly a systemic issue of unintentional errors rather than deliberate rorting by doctors.

“It’s an unpalatable truth that Medicare is in very poor shape. Compliance has become almost impossible for doctors, and the system needs urgent reform. Current punitive policing strategies are failing. They are not fit for purpose,” she said.

The paper concluded that structural reforms and a multi-pronged approach including better education and advice on Medicare billing are urgently needed to address the problem.

“This includes the development of clear, legally binding medical billing rules, nationally consistent, accurate and accessible education, and structural reform to tighten and align the underlying regulatory framework,” said Dr Faux.

The findings are published in the journal PLOS ONE.

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