Loading
“It’s above and beyond what is legitimate to charge and inconsistent with what their peers would charge for the same operation,” he said. “It is exorbitant.”
Another insider said the behaviour had been occurring for more than a decade.
A TAC spokesman said the commission took all concerns of non-compliant billing by service providers seriously.
“It is not appropriate for the TAC to comment on specific matters, nor matters currently under investigation,” he said.
“The TAC has processes in place to identify irregularities with billing and takes all possible steps to address anything that affects the integrity of the scheme.”
Loading
Surgeons say fraudulent billing is still regularly occurring at the Royal Melbourne Hospital. In addition to billing for procedures that haven’t occurred, it’s alleged that a handful of surgeons are wrongly claiming lucrative assistant surgeon fees from the TAC when they have not assisted in surgeries.
The government-owned TAC – which is funded by Victorian motorists to pay for the treatment of road accident victims – reimburses hospitals, surgeons and anaesthetists for each TAC patient they treat.
Surgeons and anaesthetists are paid an hourly rate by the hospital and also bill the TAC for their work. According to insiders, this set-up creates a perverse financial incentive for some surgeons to “harvest” TAC patients.
Hospital insiders have questioned why the alleged perpetrators were able to continue working at the hospital while under investigation.
“What is happening is unjustified and corrupt,” they said.
One of the surgeons alleged by his colleagues to be engaged in fraudulent billing told this masthead that the matter was under investigation and that the Royal Melbourne Hospital had advised him not to comment.
After this masthead first aired the allegations against the Royal Melbourne surgeons, the public hospital set up a new committee to develop a definition for appropriate billing. At the time, staff were told this would include a threshold for what constitutes an assistant surgeon.
Royal Melbourne chief executive Shelley Dolan also emailed staff to tell them she would soon contact them to discuss how the hospital could strengthen its “escalation systems”.
Loading
A Royal Melbourne Hospital spokeswoman declined to say whether these new guidelines and policies had been rolled out.
“The Royal Melbourne Hospital is proud of the care our people deliver for our community each and every day,” the spokesperson said.
“We respect the important role regulators play in the health sector and work collaboratively with them.”
Health sources say the issues at the Royal Melbourne Hospital are the tip of the iceberg, and fraudulent billing is an issue in many health services.
Two doctors at Epworth HealthCare said they had observed a surgeon regularly performing unnecessary arthroscopies, a type of keyhole surgery, on patients’ ankles to earn additional income from the TAC and health insurers.
Loading
“It is unnecessary except for rare instances to perform that arthroscopy,” one doctor said. “But this surgeon does it with monotonous regularity. It is laughable.”
Another hospital source said he had seen one surgeon regularly bill insurers for procedures that had not occurred.
“He took some screws out of someone’s ankle which takes less than five minutes, but he would put eight item numbers down,” he said, referring to the codes that are used to submit a claim for payment to private health insurers and the TAC.
A senior anaesthetist at another private hospital, who also spoke to The Age on the condition of anonymity, described pockets of certain hospitals as “rats nests of egos and greed”.
“It’s rampant profiteering,” the anaesthetist said. “There’s a difference between making a living and milking the system.”
An Epworth spokesman said it took all concerns about professional conduct seriously. He declined to say whether he was aware of the TAC investigating allegedly fraudulent billing at Epworth.
“Surgeons who operate at Epworth are not employed by Epworth,” the spokesman said. “They are independent practitioners who operate their own businesses and are credentialled to use our facilities. We have no access to, or oversight of, their billing arrangements.”
He said the hospital had not been asked to provide any information relating to Epworth’s billing practices.
“If any credible allegations are made in relation to fraudulent billing practice and brought to our attention, we will refer them to the appropriate authorities, including Medicare, AHPRA, IBAC, or the relevant funding body for investigation.”
Medical billing and compliance expert Dr Margaret Faux said medical billing fraud was widespread in Australia and would continue unless there were serious consequences.
Loading
“I have people coming to me almost daily telling me stories about bad billing behaviour, and they are too scared to speak on-the-record for fear of retribution,” she said. “That tells you everything you need to know about the toxic culture within our healthcare system.”
She said Australia needed to start treating billing fraud as a criminal justice issue like many overseas countries.
“Our prosecution processes are ineffective so basically what happens is a doctor can be found to have inappropriately billed a six-figure sum, and they get nothing more than a slap on the wrist and they are straight back at it,” she said.
“In the US, the FBI is involved in healthcare fraud and state district attorneys have dedicated healthcare fraud squads. The NHS has a dedicated counter-fraud authority [in the UK], and in South Africa it is a police matter.”
Late last year, The Age also revealed the state government had been warned in May 2022 about doctors manipulating claims to boost their income.
An independent medical examiner, whom this masthead has chosen not to name, emailed the parliamentary office of then-premier Daniel Andrews. But he never received a proper response, apart from an acknowledgement that the correspondence had been received. The same thing occurred when he sent a follow-up email.
Loading
The correspondence was sent almost a year before the Labor government bemoaned the cost blowouts plaguing the WorkCover scheme, describing the system as “fundamentally broken”.
A government spokesman said Victorians expected hospitals to uphold the highest standards of integrity and patient care.
He said as the matter was under investigation by IBAC, it would be inappropriate to comment further.
An IBAC spokesperson said: “As a matter of practice, IBAC does not comment on whether it has a complaint or investigation before it.”
The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.
Read the full article here
