Claiming and Compliance under the Medicare Benefits Schedule: A Critical Examination of Medical Practitioner Experiences, Perceptions, Attitudes and Knowledge

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Medicare is Australia’s taxpayer-funded universal health coverage system and the fourth-largest expenditure item in the federal budget. Leakage from Medicare caused by non-compliant medical billing is currently estimated at 5–15% of the scheme’s total cost ($1.2–$3.6 billion annually). Despite the absence of evidence, this phenomenon is typically attributed to deliberate abuse by medical practitioners. This unconscious bias may have its origins in a significant knowledge gap which this research investigates by examining the experiences, perceptions, attitudes, and knowledge of medical practitioners in relation to Medicare billing. The study is the first to examine the phenomenon of non-compliance from a legal, administrative and system perspective. Through a combination of quantitative and qualitative methods and a detailed doctrinal analysis of the regulatory layers of Medicare, a detailed understanding of compliance issues is presented as well as recommendations for reform. The application of the Medicare Benefits Schedule was comprehensively examined, starting with its constitutional foundations and the Federal Government’s overarching responsibility to account for public money. It was apparent that successive governments have continually tinkered with Medicare, often making misguided attempts at policy reform that have made the health payments system a morass of labyrinthine law that has become largely inaccessible and incomprehensible. This has led to rule of law problems, most notably in the areas of natural justice and the principle of legality. The research revealed a dearth of education on Medicare billing, and medical practitioners demonstrated low levels of legal literacy. Further, while legally liable for Medicare billing, medical practitioners were uninterested, preferring to delegate billing to third parties, many of whom may be significant contributors to non-compliance. The research found that a principal cause of non-compliant Medicare billing in Australia is system issues, rather than deliberate abuse by medical practitioners. Medical practitioners have no choice but to try and comply with a complex system they cannot avoid, do not understand, and feel powerless to change. Without reform, the government can expect no improvement in leakage, increased litigation and out-of-pocket costs for patients, and continued decreases in private health insurance uptake. Regulatory, educational, and digital reform are required urgently. Findings from this research can assist policymakers to ensure the efficient delivery of health care services under the Australian Medicare scheme, as well as offering important learnings for other countries as they build the legal infrastructure for the health payment arrangements that will underpin their Universal Health Coverage systems.
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