Sleep physicians feel targeted by “voluntary” Medicare billing audits

Dozens of sleep physicians have been advised to carry out “voluntary” self-audits of their Medicare billings for lab and home sleep studies in a move the Australasian Sleep Association says has left the speciality feeling “targeted” and unfairly treated.

The ASA says the Department of Health has sent letters to 79 physicians – representing the top 20% highest billers Medicare items 12203  and 12250 – suggesting they review their claims over a set period and pay back any money they have mistakenly claimed.

Sleep physicians’ claiming patterns have been under scrutiny since 2015 when the department first raised the alarm over possible inappropriate claiming of home sleep studies.

The limbic is aware of one case from 2017 where a sleep physician was made to repay $1.2 million after admitting to the Professional Services Review that they had engaged in inappropriate practice in relation to MBS items 12203 (lab-based sleep study) and 11503.

Associate Professor Garun Hamilton, chair of the ASA’s clinical committee, says the Department of Health’s position is that sleep physicians are not being singled out and the increased scrutiny on billing is part of a systematic approach across all specialty groups.

But the department’s requests for self-audits have left many practitioners feeling nervous, questioning whether it will lead to more formal probes.

“Presumably it is done to alter future behaviour, so by telling people they are being watched people will change what they do.”

There are also concerns that some practitioners have been wrongly netted in the ‘top 20%’ due to a practice of ‘figurehead billing’ used in some large sleep medicine clinics in public hospitals and private practice, says Professor Hamilton.

Under figurehead billing, a department head or practice owner will bill all sleep studies in their name, although the reporting is done by another physician.

The practice is used in other specialties and there is nothing in the MBS item descriptors to suggest it isn’t allowed, Professor Hamilton says.

But recently the Department of Health  has recently clarified with the ASA that the practice is prohibited, prompting clinics to change their billing practices.

In response, the ASA is seeking a moratorium, arguing that it is not fair to prosecute retrospectively when the rules were not spelled out. The ASA has yet t receive a response from the Department.

Professor Hamilton said the whole debacle had left some feeling unfairly targeted.

“Anecdotally some of the physicians who have been sent these letters have found it very stressful. That is significant, you can’t neglect the human side of all this activity from the department.

“There is a general feeling that we have been targeted…whether that’s fair or not others can judge, certainly other areas of medicine have not been put under the same scrutiny as we have over the last couple of years.”

The limbic has contacted the Department of Health for a response.

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