Medicare’s systemic denial artificially inflates official statistics showing that nearly nine out of 10 patients receive wholesale bills from their doctors and pay no out-of-pocket costs.
Key points:
- Phenix Health billed some patients at the same time as the fee, the documents show
- Patients are required to “consent to bill” on the booking form
- Some cases involved Medicare charges that inflated the length of the consultation
A joint Medicare investigation by ABC 7.30, The Sydney Morning Herald and The Age has uncovered errors and wrongdoing by health professionals that are skewing national figures.
Some experts are convinced that the mass bill is much lower: about four to six for every 10 visits to the doctor.
Leaked documents show that one of the nation’s largest telemedicine companies, Phenix Health, billed some patients at the same time as charging them, which is illegal under the Health Insurance Portability Act.
A legal method for doctors who do not bulk bill is to charge the patient, who then receives a rebate from Medicare.
Dr. Margaret Fox, a lawyer with a PhD in Medicare claims and compliance, said carriers who charge fees and then bill in bulk for the same service have skewed Medicare statistics. She says about four out of 10 patients – not nine out of 10 – don’t pay out of pocket to see a GP.
In August, The Australian cited figures released by the Primary Care Business Council, a lobbying group representing some of the country’s biggest GP operators, which estimated the mass Medicare payment rate was about 61 per cent, or 6 in 10 patients.
Questions about the accuracy of the data prompted a departmental review of Health Minister Mark Butler.
However, Dr Fo called on the government to make the review independent and more comprehensive. She estimated that up to $8 billion is lost to Medicare each year due to fraud and noncompliance, nearly 30 percent of Medicare’s current $28 billion in annual costs.
Awareness of potential illegality
The revelations come as GPs are lobbying the government to increase bulk billing discounts, arguing that bulk billing is in crisis and they can no longer afford to offer it unless the Medicare rebate is increased.
Dr. Fox, whose Synapse Medical Services business is paid by doctors, hospitals and corporate medical practices to process their Medicare bills, recently dropped Phenix as a client.
Asked about Phenix after patients contacted the 7.30 Herald and The Age with concerns, Dr Fox said billing service Synapse had processed more than 30,000 Medicare bulk billing claims for Phenix over two years until August of this year.
That amounted to more than $2 million in rebates. Dr. Fo canceled the contract after learning of the potential illegality.
Phenix’s website says it’s a mixed billing practice that “requires a $35 out-of-pocket payment for all bookings for patients with a valid Medicare card to be billed at the Medicare Benefits Scheme rate.”
Patients are required to “consent to bill” on the booking form. The website also states that private reservations are available for a fee of $48.
Some cases involved Medicare charges that overestimated the length of the consultation, attracting a higher rebate.
“Improper billing like what Phenix did is illegal”
Phenix charged some patients as much as $38 for a nurse practitioner consultation and then billed them in bulk, which is illegal, the documents show.
In one case, the consultation lasted less than two minutes, but Medicare records show that Medicare also billed for a consultation lasting at least 20 minutes, which pays $35.70 per nurse practitioner. The correct amount is $18.85.
In one case, a patient paid $50 online for a consultation with a therapist about quitting smoking. The consultation, which took place while the doctor was driving, lasted several minutes.
Phenix then bills Medicare for a GP smoking cessation consultation that lasts at least 20 minutes for $76.95. The correct Medicare bill was to be $39.75 in less than 20 minutes.
Medicare records show that the “cost to the claimant” was zero, even though the patients had no money to pay, which skews the official figures.
“Inappropriate billing, like what Phenix did, is illegal,” Dr Fo said.
Phenix was sent a series of questions. He responded with a statement saying “the allegations in your email were inaccurate and damaging.” It said Phenix only has two doctors with Medicare provider numbers, and they use the provider numbers only under collaborative agreements with nurse practitioners. “The rest of our GPs bill privately,” it said.
However, Dr Fo said Phenix, which boasts on its website that it is the “highest quality virtual super clinic” in Australia, had 29 GPs and 20 nurse practitioners actively billing on the Synapse system when she was a client until August of this year.
Phenix said it is aware of the complex rules for using Medicare item numbers for billing purposes and always strives to ensure that its billing methods comply with those rules.
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https://www.abc.net.au/news/2022-10-18/medicare-bulk-billing-statistics-aritificially-inflated/101544098
