Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

Margaret Faux,Simran Dahiya,Jon Wardle,Jon Adams,Kathleen Finlayson

doi:10.1371/journal.pone.0262211

Abstract

Medical billing errors and fraud have been described as one of the last "great unreduced healthcare costs," with some commentators suggesting measurable average losses from this phenomenon are 7% of total health expenditure. In Australia, it has been estimated that leakage from Medicare caused by non-compliant medical billing may be 10-15% of the scheme's total cost. Despite a growing body of international research, mostly from the U.S, suggesting that rather than deliberately abusing the health financing systems they operate within, medical practitioners may be struggling to understand complex and highly interpretive medical billing rules, there is a lack of research in this area in Australia. The aim of this study was to address this research gap by examining the experiences of medical practitioners through the first qualitative study undertaken in Australia, which may have relevance in multiple jurisdictions. This study interviewed 27 specialist and general medical practitioners who claim Medicare reimbursements in their daily practice. Interviews were recorded, transcribed, and analysed using thematic analysis. The qualitative data revealed five themes including inadequate induction, poor legal literacy, absence of reliable advice and support, fear and deference, and unmet opportunities for improvement. The qualitative data presented in this study suggest Australian medical practitioners are ill-equipped to manage their Medicare compliance obligations, have low levels of legal literacy and desire education, clarity and certainty around complex billing standards and rules. Non-compliant medical billing under Australia's Medicare scheme is a nuanced phenomenon that may be far more complex than previously thought and learnings from this study may offer important insights for other countries seeking solutions to the phenomenon of health system leakage. Strategies to address the barriers and deficiencies identified by participants in this study will require a multi-pronged approach. The data suggest that the current punitive system of ensuring compliance by Australian medical practitioners is not fit for purpose.

Highlights

IntroductionMedical billing errors and fraud have been described as one of the last “great unreduced healthcare costs,” with some commentators suggesting measurable average losses from this phenomenon are 7% of total health expenditure [1]
The qualitative data presented in this study suggest Australian medical practitioners are illequipped to manage their Medicare compliance obligations, have low levels of legal literacy and desire education, clarity and certainty around complex billing standards and rules
The data suggest that the current punitive system of ensuring compliance by Australian medical practitioners is not fit for purpose

Summary

Introduction

Medical billing errors and fraud have been described as one of the last “great unreduced healthcare costs,” with some commentators suggesting measurable average losses from this phenomenon are 7% of total health expenditure [1]. How much non-compliant billing is deliberate is uncertain, as it rests in a spectrum with criminal fraud at one end and unintentional errors at the other and currently the precise quantum of each is unknown. This is largely because the problem is not what can be seen, but what cannot. Despite a growing body of international research, mostly from the U.S, suggesting that rather than deliberately abusing the health financing systems they operate within, medical practitioners may be struggling to understand complex and highly interpretive medical billing rules, there is a lack of research in this area in Australia.

Objectives

Discussion

Conclusion