‘An impossible-to-navigate mess’: GPs ill-equipped to handle Medicare compliance, study finds

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The first qualitative study of practitioners’ billing experiences in Australia highlights the need for urgent structural reforms.

GPs say there is a lack of training and education, as well as an absence of reliable advice and support, around medical billing – even from Medicare.


Medicare compliance is a persistent problem for GPs and other clinicians in Australia.

Errors can have consequences for healthcare providers, patients, and taxpayers, with up to 15% of total Medicare Benefits Schedule (MBS) costs estimated to be the result of improper billing.

But new research has added to a growing body of evidence that suggests it’s not doctors deliberately abusing the system, but rather clinicians struggling to understand what can be a complex system, with highly interpretive billing rules. .

Posted in PLOS ONE, researchers from UTS, UNSW and Southern Cross University conducted in-depth interviews with 27 GPs and non-GP specialists in NSW who seek Medicare reimbursements in their daily practice and identified five key issues:

  • Little or no introduction or training around medical billing
  • Lack of knowledge and understanding of basic legal requirements
  • Lack of reliable billing advice and support, even from Medicare
  • Doctors are afraid of making billing errors
  • Unmet opportunities for improvement

Lead author Dr. Margaret Faux, who completed a doctoral dissertation at UTS on Medicare demand and compliance, said the findings indicate the system needs “urgent reform.”

“It’s an unpleasant truth that Medicare is in terrible shape. [and] compliance has become nearly impossible for physicians,” she said.

“A single Medicare service in Australia can be subject to over 30 different payment rates, multiple claim methods and a myriad of rules, [and] ongoing changes due to COVID-19, such as those around telehealth, also add to the confusion.

Dr. Faux also describes current policing strategies employed by the Department of Health (DoH) as “punitive” and “not fit for purpose.”

The research is the first qualitative study to examine the experiences of medical practitioners in Australia.

Tasmanian GP and practice owner Dr Emil Djakic, who is a member of the RACGP – Funding and Health System Reform (REC-FHSR) Expert Panel, said the results were not surprising.

He said newsGP that despite being “pretty literate in MBS”, he still struggles to navigate the system.

‘It has been 15 years now that the Team Care Arrangement item number [was brought in] and in our practice we still sit down regularly, at least every three or four months, to have interpretation discussions on this article number,” said Dr. Djakic.

“We’re still struggling to figure out exactly how we make sure we’re complying or using it for its best intentions.

“GPs and especially the younger cohort, our registrars and new fellows, are really struggling.”

Dr Djakic thinks the billing issues are largely because the MBS is unnecessarily complex, describing it as “an unnavigable mess for all but a few”, which he says is underpinned by regular changes of goals.

“I believe most GPs are seriously trying to make the most of a funding hodgepodge on [item] numbers,” he said.

“But Medicare has evolved from an insurance tool for funding patient health care to a measure of quality and standards that the government tries to use to manipulate productivity and spending.

“So he’s now trying to ride multiple horses and he’s doing it badly, and a lot of people are falling because it’s no longer fit for purpose.”

Dr. Djakic agrees that more emphasis needs to be placed on education. He said the REC-FHSR had made efforts to partner with the Department of Health to work on a ‘less punitive’ approach to better support GPs’ knowledge of the system.

“We prefer to walk alongside the department and help improve utilization and better facilitate funding for patients because unfortunately I fear that millions and millions of dollars available for patient healthcare are bypassing patients. each year due to general medical literacy issues,’ he said.

“But we have to accept that these descriptors are very difficult and there are also a plethora of them now. I don’t know how a patient feels, but every time they leave my office…the same service apparently has a different item number.

“Now if you went to the store and bought a carton of milk and each time you bought a carton of milk you were charged a different price, you would start to think there was something wrong with that supermarket.”

Although Dr Djakic has in the past advocated for the MBS to be further integrated into the general medical curriculum, he says this will not solve the fundamental problems of a system which he believes needs to be modernized – starting with a fair funding.

‘Incentives to jump through the hoops [have] turned [this] in a ‘tail wagging the dog’ scenario,” he said.

“People sometimes do item numbers because they know it will improve the patient’s access to funding for care, but may not necessarily result in a lot of change for patients. But it shouldn’t be designed that way – patient insurance should be tailored to the effective care you provide on the day, all those other item numbers just cause distractions.

“This, again, emphasizes fee-for-service as the only modality – but that doesn’t work in chronic conditions. So [personally], I’m ready to basically rip the MBS and start over, at least in the GP space.

While the new research does not advocate a complete overhaul of Medicare, Dr. Faux says the study makes it clear that a multi-pronged approach is needed to better equip doctors to manage their compliance obligations.

In her doctorate, she made 27 recommendations covering regulatory, educational and digital reforms to help modernize and streamline the system.

“Doctors currently have no choice but to try to conform to an incomprehensible system that they don’t understand and feel powerless to change,” Dr. Faux said.

“Without reform, the government cannot expect any improvement in leaks and non-compliance.”

RACGP members can access a range of helpful Medicare interpretation and compliance resources through the RACGP website, including:

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