Rorting Health Practioners Busted

by Ann Samuel on  July 20, 2007 at 1:01 PM Health Insurance News   - G J E 4
Rorting Health Practioners Busted
After a major crackdown on them, erring doctors and other health specialists have been ordered to repay $4.3 million for rorting the federal health system, since 1999.

Members of the Professional Service Review, (PSR) which investigates and punishes health practitioners who claim Medicare Benefits or prescribe Pharmaceutical Benefits Scheme (PBS) drugs "inappropriately", carried out the search.

The search is peer-reviewed and designed to protect patients as well as government coffers from doctors, dentists, physiotherapists, chiropractors and other specialists who over-prescribe, over-refer or claim for too many consultations.

Doctors can be referred to the PSR if their practice or test ordering patterns seems unusually high. This might be due to legitimate reasons, or a genuine misunderstanding of the requirements.

The PSR has almost ground to a halt since 2004, partly due to a plethora of lawsuits from targeted doctors, and a reduced number of doctors being referred by Medicare for investigation.

In 2005-06, Medicare cost the Government $10.8 billion, while the PBS was estimated to have used $6.2 billion in the same financial year. The reviewers considered 313 cases of possible inappropriate practice, based on Medicare and PBS data, between 1999-2000 and 2005-06.

Sanctions were imposed on 111 practitioners, including 84 who were ordered to pay back an average $49,270, the report made known. Dozens of other practitioners were disqualified from making any Medicare claims for a set period, and seven were suspended from prescribing PBS drugs.

"This resulted in savings to Medicare of $4.3 million in benefits repaid and an estimated $12.9 million in benefits not paid due to partial or full disqualification from Medicare eligibility," Health Minister Tony Abbott was quoted.

At the same time, the review also questioned whether the sanctions were enough to deter doctors, particularly from inappropriate PBS prescriptions. It recommended that the government consider tougher rules.

The report also warned that the movement of corporations into general practice was creating new problems. There was potential for "negative corporate influence" to encourage GPs to make unnecessary referrals to their other services by giving performance pay and bonuses, the report said and recommended their conduct be monitored and the government introduce legislation that would allow them to be punished.

A GP is deemed to have practiced inappropriately if they make 80 or more Medicare Benefit claims on each of 20 days in a 12-month period, unless exceptional circumstances apply.

There are moves to widen the PSR to cover health workers other than doctors who qualify for Medicare or Pharmaceutical Benefits Scheme subsidies. Also, new penalties will punish medical corporations found to be working the system for financial advantage. The recommendations cited in the report have won cautious approval from the Australian Medical Association.

Source: Medindia

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