Senior Department of Health, Disability and Ageing officials say doctors will soon have better visibility over what gets claimed under their provider number.
This year’s budget promises savings of $674.1 million over four years by stamping out MBS and PBS non-compliance and fraud, as the Department of Health, Disability and Ageing starts to move away from relying on tip-offs about bad behaviour.
The savings measure itself appeared as a line item in the budget, with no detail on what it would actually involve.
At a Senate Community Affairs Legislation Committee estimates hearing on Wednesday, shadow health minister Anne Ruston pressed DoHDA first assistant secretary of benefits integrity Matthew Williams for more information.
Mr Williams said it was part of the government’s continued response to the Independent Review of Medicare Integrity and Compliance completed by Dr Pradeep Philip in 2023.
“[The report concluded] that the integrity approach that the government took focused too heavily on post-payment compliance measures, and those measures were reliant on data of payments that had already happened and pursuing practitioners that were operating outside of regulations,” Mr Williams told the senate estimates committee.
“The Philip review also identified that … there could be greater benefits in avoiding non-compliance and fraud if some of those measures and efforts were up front.”
Some of the recommendations from Dr Philip’s report were to implement technology to enable consistent and complete pre-payment checking and validation of all MBS claims, force practice management software to enable real-time claims assessment and institute more formal and deliberate feedback loops within DoHDA and Services Australia.
“This budget measure takes forward additional reforms and modernisation of Medicare integrity that has been happening for some time,” Mr Williams said.
“The first element is the ongoing reform and innovation capability. The previous two measures the government implemented set up a task force to respond to Philip review recommendations and work with Services Australia to implement and update and modernise.
“This measure provides ongoing support for that capability going forward, and it does also provide support for up-front controls.”
While he did not get into specifics, Mr Williams said the measure would allow practitioners and patients “to see what is actually happening in billing” under both their names.
More importantly, it will allow doctors to better understand whether they are compliant.
“Some institutional or corporate arrangements have meant that [doctors are unknowingly] non-compliant,” the DoHDA official said.
“For instance, sometimes a practitioners’ Medicare provider number will be utilised when a locum is in in town rather than the locum’s provider number, so there is a non-compliance issue there.
“Having better visibility allows practitioners to better govern their own actions.
“It also provides ability for patients to see their own billing under their names as well. There is some visibility at the moment, this would make it that more easily accessible.”
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Ms Ruston also questioned whether the department intended to use AI or algorithms to detect non-compliance.
Mr Williams confirmed that DoHDA had moved away “simply from relying on tip offs from the public” to directing its compliance efforts.
“We have invested in increased analytic capabilities and our ability to understand and compare data sets,” he said.
“As technology evolves, we have started to rely on things like machine learning and advanced analytics to compare data sets like demographics of particular population groups and the billing behaviours of practitioners in those population areas; home affairs data, for instance, about whether practitioners are in the country or out of the country.
“Those new technologies have allowed us to do greater analysis of areas and issues of concern … but there’s no intention that there’ll be the use of AI to make any compliance determinations.
“AI and advanced analytics would only be used and are only used currently to support our identification of issues of concern which are then individually investigated by the department.”
Estimates hearings continue on Friday.
