Holding the elephant’s trunk and calling it a snake

6 minute read

Two psychiatrists’ attempt to use MBS data to make a point about practice was shockingly inaccurate, irresponsible and unjust to GPs.

By the time we had our first meeting, the lawyers said they had contacted the authors of every academic textbook on the Australian health system.

They said they assumed that those authors would be the appropriate experts, given the textbooks. But the authors had advised that they could not help them with their Medicare law questions.

I pointed out that the shortest sections of those books were those on the MBS, and that they said little more than “go to the MBS website for more information”. How Medicare law is applied in practice was noticeably absent from all of them.

But at least the authors were honest about their lack of Medicare and MBS expertise. Not so the two eminent psychiatrists* who recently published an opinion piece in MJA Insight that sought to glean meaning from MBS codes that was not there.

As the only Australian with a PhD on Medicare claiming and compliance, I am used to dealing with self-proclaimed experts in my area of research. They’re everywhere. But it was still a shock to observe two non-Medicare-experts publish an opinion piece, drawing on MBS data, that was not only inaccurate, but also terribly unfair and insulting to GPs.

What the psychiatrists failed to understand were Medicare basics, and their dearth of knowledge was alarming.

In their article, they suggested that because mental health treatment plan (MHTP) MBS review items were not being billed on parity with the initial plan preparation items, that this somehow indicated GPs were not doing the follow-up work.

This was not only incorrect, but also irresponsible messaging.

Firstly, MBS data are service codes, devoid of context, and currently, the only meaning that can be gleaned from them is that the system is being used. They tell us nothing about whether the system is being used correctly or incorrectly, largely because of poorly drafted item descriptions, confusing rules, unfair policing, and legacy structural problems. MBS data therefore tell us little more than whether use is going up or down or is remaining steady. MBS data definitely do not provide evidence of whether GPs are servicing the mental health needs of their patients or not.

Secondly, the psychiatrists erred in relation to the threshold legal requirement for claiming Medicare benefits. That is, that the service must be clinically relevant, defined in the Health Insurance Act 1973 (Cwth) as “necessary for the treatment of the patient as judged by peers”. “Necessary” being the operative word.

The fact that an MBS item is available and can be billed, does not mean that it should be billed, and at a time when Medicare policing is more aggressive than I have ever seen it in all the decades I have been doing this work, articles like this set us back and cause untold damage.

Because an implied message conveyed by the psychiatrists was that GPs are not billing enough and should bill more. But the MDOs and I have been working hard to get the opposite message out to GPs – that they should bill less, and never bill an item number just because they can.

The law does not permit GPs (or anyone) to bill Medicare for unnecessary services, which is adjudicated in a completely subjective way. So, while Professor Ian Hickie may be of the view that it is necessary for every MHTP to be reviewed, the Medicare police do not agree, and the Medicare system is not designed to be used in that way.

There are many PSR case reports in which GPs have followed the approach of these psychiatrists and billed plenty of MHTP review services, but unfortunately, this made them statistical outliers so they had to pay all the money back, irrespective of whether the services were deemed necessary.

I suppose the inaccuracies in the article are not so surprising when you consider that most psychiatrists bill a relatively small subset of time-based MBS items, that are neatly divided between inpatients and outpatients. No other craft group has it so (relatively) easy. In addition, their work comprises mostly long consultations which makes them less of an audit target, and because they only do one thing, they don’t receive nudge letters.

There are almost no private psychiatrists who bulk bill, so they also avoid PSR scrutiny and therefore do not live in fear of Medicare audits. In fact, only three psychiatrists have been named in the PSR case reports in the last five years, compared to hundreds of GPs. Those three would have been rare bulk billers (outpatients) and using gapcover schemes (inpatients), because the department would have been unable to claw back the money otherwise.

I have regular calls with panicked doctors who have received a threatening letter of some description from the department, or who are being forced into false confessions by the PSR, or who are too scared to bill something or other, and are desperate for advice.

In a recent PSR matter, the bias of the PSR committee was so obvious in the hearing transcripts that even I found it shocking, and I’ve read quite a few. The committee members were also clearly not peers of this excellent GP (the committee commended his clinical skills) who is being savaged for not adding a bit more detail to his contemporaneous notes.

These psychiatrists have absolutely no idea about how general practice or Medicare works, but have unfortunately been given a platform to display their ignorance via a prominent outlet. This also raises legitimate questions and concerns about the accountability and editing process at MJA Insight, because someone should have fact checked the core tenet of the article and reconsidered the decision to publish.

If there is a positive in all of this, perhaps it is that there is a clear message for the government: Medicare reform needs to be led by experts who understand the whole system, not just the trunk.

Dr Margaret Faux is a health system administrator, lawyer and registered nurse with a PhD in Medicare compliance, and is the CEO of AIMAC, which offers courses and explainers on legally correct Medicare billing.

*Dr Sebastian Rosenberg is a lecturer at the Brain and Mind Institute at Sydney University with a PhD in accountability for mental health, not a psychiatrist – TMR is sorry for not having fact-checked this.

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