What does Medicare data matching reforms mean for GP’s?

The Federal Government has finished receiving submissions on its Health Legislation Amendment (Data-matching) Bill, and we are now waiting to see how the law will appear in its final form. The Bill proposes Medicare data matching to combat fraud.

Fraudulent Use of Medicare:

The consultation guide issued in September this year makes a strong argument for matching existing data from a range of sources to help combat fraudulent use of Medicare.

And while the majority of people do the right thing – there are always those few who will try to circumvent any system for their own gain.

Essentially the proposal is such to enable a scheme of data matching for permitted Medicare compliance purposes.

Basically this means using data from different sources to see who is not using the system legally.

Some Facts:

  • In 2018-19, the Australian Government spent $37.1 billion on Medicare and other health services.
  • If only half of a percent of Medicare payments are fraudulently, incorrectly or inappropriately billed, around $180 million of health benefits is lost that could have otherwise contributed to essential health services for Australians.

We can appreciate the need for the Government to tackle fraudulent claims, let’s dive a little deeper.

How is Fraud Currently Tackled?

Currently it’s a combination of:

  • Tip offs
  • Analysis of Medicare information to identify inconsistencies

Relying on tip offs is certainly not a “fool proof system” and in this day and age, this seems like a rather antiquated way to manage fraud when so much information and data is at the Government’s disposal.

How The Proposed Legislative Changes Will Improve Detection:

The Bill enables the matching of specific data-sets with other prescribed Australian Government Agencies.

Including:

  • Medical Benefits Schedule
  • Pharmaceutical Benefits Scheme
  • Therapeutic Goods Information
  • AHPRA registration information
  • Department of Veterans Affairs
  • Information voluntarily provided by Private Health Insurers; and
  • Other lawful information such as whether a person was in Australia at the time a claim was made 

Matching all these data sets together, it is intended, will provide a broader scope of information and understanding and identify where there are inconsistencies and anomalies in claims.

For example, matching a patient’s claim with whether they were in the country seems an obvious one.

Likewise, if a practitioner with restrictions on their registration were to bill for items they’re excluded from, that warrants identification and correction.

But What About Privacy?

The consultation guide offers reassurance that the matching of data sets will only be authorised for “Medicare compliance related purposes” such as detecting deliberate fraud and incorrect claiming.

In a time when Data Privacy is paramount and steps are being taken to REDUCE the instances in which information is shared with the wrong party – legislation like this can seem to go against the grain.

The Government has declared that any breaches under the proposed legislation will be treated in line with the Privacy Act 1988.

What Does This Mean For Patients?

Patient data will be shared across multiple parties and platforms.  It is possible that you will need to make patients aware of this should legislation changes occur.

It’s also a good time to be checking privacy policies in your practice.

The legislation is planned to go before the lower house in the coming weeks. 

Watch this space for more information. 

More Reading:

AMA Submission

Consultation Paper