The Australian government says nearly nine out of ten GP visits are billed in bulk, but a health insurance researcher says gaps are often not recorded, meaning the official data is “a big lie”.
Andrew James*, his wife and their two children were billed in bulk for 15-minute appointments at their Sydney GP clinic over three years, with their Medicare records showing they paid “$0”.
However, with each appointment, James and his family were charged a $35 gap fee as a separate Eftpos transaction.
“There was nothing in our medical records that recorded this money as a cash expense,” he said.
“I’ve tried to deal with it with the clinic, but I haven’t pushed too hard because there aren’t many places to go near me and the doctors there are very good. In their defense they’ve been billing my flu shot in bulk since Covid because of my asthma, and sometimes they wouldn’t charge the hole for the kids, but not that often.”
At GP appointments alone, the family paid about $300 a year, despite the official $0 figure on their records.
dr. Margaret Faux, a health insurance law attorney and academic, recently published her PhD on Medicare claiming and compliance. She says the experience of James and his family shows why the government’s bulk billing data has been drastically inflated and “is a big lie”.
“It’s an example of a common problem that completely skews bulk billing statistics,” said Faux, who is also a registered nurse.
“As far as the Government is concerned, that busy Sydney practice was a bulk billing practice until last July and their patients were not paying out-of-pocket charges, which was not true. In fact…patients at that practice paid $35 cash and were billed in bulk. , but the $35 was never seen on data collected by the government and never will be.”
This kind of billing is illegal, Faux said, but her doctoral research showed it was widespread. Faux is the founder and CEO of Synapse Medical, which teaches healthcare providers how to legally bill their patients. Medicare’s billing system is so complex, she said, that educational services like hers were needed.
“The other problem with not charging gap fees correctly is that it prevents patients and their families from reaching safety net thresholds, which are there to lower their out-of-pocket costs,” Faux said.
“The safety net only comes into effect when you have paid a certain amount out of your own pocket. But if the government does not see your out-of-pocket costs, because they are charged on a separate Eftpos transaction, then you will not meet the threshold.”
The academic says many clinics are unaware that they are billing illegally because the practice has become so common. What should happen is either the patient will be billed in bulk and not pay any money – or they will be charged a private fee, some of which will be refunded directly to the patient’s bank account by Medicare. The clinic that James now attends does this.
But many clinics claim the discount for themselves and charge the patient a separate hole.
Faux said everyone should log into Medicare and review their records and look at the “claimant expense” column. If a cost in that column says $0, but you paid for the service and you paid nothing, something was probably wrong, she said.
“This is a huge problem that I see or hear very often in my day-to-day work, which is why the bulk billing stats are essentially bullshit,” she said.
The coalition has repeatedly bragged about bulk billing rates in the run-up to the election. A spokesman for the federal health minister, Greg Hunt, said: “GPS bulk billing rates reached 89.6% in the July-September 2021 quarter… patient costs.”
In March, Hunt issued a press release stating: “Essential medical care is more affordable than ever before as the number of Australians receiving essential out-of-pocket medical care continues to rise.”
Out-of-pocket health costs are a major issue for patients, says Consumers Health Forum (CHF) chief executive Leanne Wells.
“We’ve been skeptical about claims of high bulk billing rates for a while,” she said. “The rates do not reflect people’s experience when they find it difficult or impossible to find a bulk billing physician.”
To address rising out-of-pocket health costs, medical agencies, including the Australian Medical Association and the Royal College of General Practitioners, argue that Medicare rebates for patients should be increased.
The AMA president, Dr. Omar Khorshid, said freezing rebates across both major parties meant a patient’s Medicare rebate growth rate was below inflation and wage growth.
“In real terms, GPs are being asked to do more with less and this is impacting the viability of the practice and access to services for patients,” he said.
The CHF agrees that increasing rebates would boost primary health care. “If the discount were increased, it could encourage more realistic bulk billing,” Wells said.
Neither the Coalition nor Labor promise to increase the rebates. Faux believes it should, but also argues that until the problem of billing non-compliance and a dysfunctional Medicare system is addressed, increasing the rebate would do little to reduce out-of-pocket costs.
“Suppose we increase the discount from $39 to $40. Do you really think that the GPs who bill incorrectly and charge, say, a $35 ‘gap’, will reduce that amount to $34? Obviously not. just put it in his pocket, that won’t ease the out-of-cost burden for this consumer.
“So until we fix the broken, non-compliant business model, we can’t increase the discount.”
Faux said erroneous billing was not detected by government compliance officials because it was so common and didn’t show up on Medicare records as an outlier.
Anthony Scott, professor of health economics at the University of Melbourne, agrees with Faux that bulk billing statistics are inaccurate. He praised her work on billing and said she was the first to take it seriously.
Scott said out-of-pocket health care costs were rising faster than wages and faster than other consumer prices — and none of the major parties had offered significant policies to address the problem.
In addition to rising GP costs are specialist costs, where there is little transparency about out-of-pocket costs and reimbursements. Scott said it can be harder to “shop around” for a specialist appointment because waiting lists are long, referrals are hard to get, and appointments are scarce.
“Specialists just aren’t touched by calls for reform,” Scott said. This is despite only 35% of specialist consultations being billed in bulk in 2020-21, he said. Less affluent people with more pressing health needs are also disproportionately affected by these fees and are forced to get on public lists where wait times are longer.
“There’s even less oversight and data when it comes to the specialist side of the healthcare cost debate,” Scott said. “In oncology, for example, an increasing share of cancer care is provided by the private sector. And when you have cancer, you just want to get rid of it as soon as possible. You don’t have time to shop.”
*Name changed for privacy reasons
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