MIGA’s new Claims Hypothetical explores the Medicare audit and what it might mean for you.

In 2018, the Department of Health raised $49 million in debts from health providers for incorrect billing1. This was $20 million more than the year before.

The Department of Health is responsible for administering and protecting the MBS and PBS Schemes by ensuring compliance.

In the Department’s own words compliance ensures, “we provide the right payment to the right person at the right time.”2

Incorrect payments to world health systems is estimated to be around 7% of the total global health expenditure or $487 billion (in 2014)3. In Australia some commentators have suggested the cost of overpayment is more like 10-15% of the scheme’s total cost annually or $A2-3 billion.4

This new hypothetical will explore the audit process, which begins with the Department of Health and may progress to the Professional Services Review (PSR), Medicare’s “watchdog”.

Having to repay benefits can be the least of your worries:

  • Penalties can apply and findings of inappropriate practice can result in suspension of provider benefits with loss of income and reputational damage
  • The PSR can also make referral to AHPRA and the Medical Board
  • Where fraud is suspected the matter can be referred to the Australian Federal Police for criminal investigation.

At each referral, the potential “bite” that can be inflicted can lead to even more serious complications.

The Government will be investing more into compliance activities such as data matching and expanding its focus on examining the billing practices of GPs, specialists and health entities.

Now is not the time to be complacent. Understand Medicare’s concerns and whether you could be vulnerable if you become the focus of an audit.

Book to attend one of MIGA’s risk events via REO – https://reo.miga.com.au/d2l/login  

1 Based on 2017-2018 cost in benefits of $23.2 billion
2 eLearning Module: Introduction to Compliance within Medicare
3 Gee J , Button M  The Financial Cost of Healthcare Fraud 2014; quoted by Faux M et al. Who teaches medical billing? A national cross-sectional survey of Australian medical education stakeholders. BMJ Open 2018; 8:e020712
4 Faux M ibid; referencing Webber TD. What is wrong with Medicare? Med J Aust 2012;196:240–9.doi:10.5694/mja12.10286

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