Trainees absorb bad practices by example or instruction, and then are hung out to dry.
When a doctor bills incorrectly, whether deliberately or unintentionally, there’s collateral damage.
Trainees can be set up to fail, or worse, commit crimes, and support staff may be intimidated into complicity.
A number of my colleagues at the MDOs have told me they’re commonly called up on to give medico-legal advice to junior GP registrars who are trapped in toxic billing environments, where they are basically forced to bill for things that did not happen.
While the precise size of this phenomenon, which is underscored by contempt for Medicare, is unknown, there is evidence of widespread problems that may even begin before students graduate from medical school. In a conversation I had with a medical student, who had completed a GP placement, this is what they said about the Medicare billing in the practice:
“The GP puts some numbers in at the end of each consultation, and then the practice manager seems to often call a few moments later to change the numbers. She says ‘can you make it one of these and this instead’, and the GP says ‘sure, yeah, whatever’. And I’m watching all of this thinking, this man is my mentor, this person is teaching me how to be a GP and how general practice works, including how to bill to Medicare. So, I assume that’s how everyone does it. That must be how it works.”
Early in my doctoral journey, I received an anonymous letter that stopped me in my tracks and troubled me deeply. The explicit details of a medical receptionist’s experiences with illegal billing were shocking. So alarmed and upset was the author, that they sent copies of the letter to the Prime Minister, and various other politicians and the media, in the hope that someone would take notice.
The author did not indicate whether the practice was training registrars, though the doctors are described as good doctors clinically, so perhaps the practice was accredited for training. Imagine what those poor registrars would be learning about Medicare if that assumption is correct.
In the high-profile legal battle between Dr Anchita Karmakar and the PSR, one of the most unsettling aspects of the case from my perspective, was that Anchita was a registrar when she was investigated. I followed the commentary throughout, and not once did I see any of her colleagues mention the fact that she wasn’t even fully qualified, or question the role and responsibilities of her mentor. If her billing practices were so bad so early in her career, how did the profession let that happen? Who was supervising her and why didn’t that person pull her aside earlier and help her understand what she was doing wrong before it escalated?
Sadly, it therefore came as no surprise to me to learn that the illegally billing doctor at the centre of the Shane Solomon/Medinet/covid telehealth debacle last year, was a registrar. It raised the same questions for me: who was mentoring this registrar and where did he obtain his “education” on correct Medicare billing? Was he just doing what he had seen his mentor do? What everyone does?
Why is the profession not protecting its young?
The answer to that question is complex. While my research found some commendable attempts to teach correct use of Medicare, the overwhelming responses of doctors who participated in the qualitative interviews was that their education in this important area was deficient. They expressed their views in clear, unambiguous terms, summarised by the following typical response.
“[Education was] absolutely, totally, totally [inadequate]. Part of the problem, it is very interpretation based, there is no clarity on it. That’s really poor and there isn’t, to my knowledge, any kind of place that we can go, that in a succinct fashion, in a way that we need it to be, we can have very clear guidance about what we can or we cannot do and I strongly feel that I’ve had to wing this in terms of pulling stuff together, to make my own knowledge on it.”
We know the MBS is incomprehensible and we know it is a systems of laws. There has never been a standardised, national curriculum on the topic, and doctors are not qualified to teach law. So, we are left with a vortex of misinformation and myths of Trumpian proportions, that are contributing to massive system leakage.
But at the heart of the problem is the system, not the doctors. Doctors will use the system put in front of them, so we have to make it a system that is firstly able to be understood, and then, has fewer regulatory gaps.
This will require a multi-pronged approach including putting in place controls to improve visibility, and the use of regulatory tools to pull up aberrant behaviour quickly. Think of it like speed cameras: they don’t stop some people from speeding, but they have had a huge impact on improving road safety. If we know speed cameras are there, we slow our speed, and if we get caught speeding, the fines are high enough to hurt, so we adjust our driving behaviour quickly.
When it comes to medical billing prosecution, instead of a modern, digitally enabled approach like speed cameras, we instead have an old fashioned “pay and chase” system powered by the draconian PSR agency. We can and must rethink this, so we can better protect all doctors, including junior doctors who are currently set up to fail.
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