Questionable evidence and argumentation regarding alleged misuse of Medicare

We write in response to a recently published paper on Medicare Item billing that extrapolates from a case study of the billing of a surgical service item to conclude that clinicians, through potentially fraudulent activity, are the major causal agents of non-compliant billing.¹ Questionable evidence-base and argumentation within the paper do not support the conclusions.

The ‘Individual Clinicians’ section contains two paragraphs of unreferenced assertions, that clinicians either avoid billing incorrectly or bill more than they are entitled to.¹ There follows an unreferenced assertion that clinicians do not receive training in billing, predicated on the unsupported assumption that training is required, and therefore that professional advisers are needed. The second paragraph of ‘Medicare’ contains extensive unreferenced assertions regarding the integrity of the billing process. These sections appear subject to the logical fallacy of begging the question – assuming unsupported facts as a basis for debate.

We refer to the section beginning: ‘Successive governments have known that non-compliant Medicare billing is a major problem but have lacked the political will to do anything about it….’ which references research from Dr Margaret Faux and Dr Pradeep Philip.¹ The paper does not represent a full and accurate representation of Dr Faux’s research,^2,3 or of Dr Philip’s report.⁴ The paper’s assertion that clinicians create non-compliant billing is not supported by an in-depth reading of the quoted sources. Dr Faux’s thesis states (p. 77) ‘…quantifying the precise monetary value attributable to inappropriate claiming has proven an impossible task’.³ Dr Philip stated: ‘… it is my view that a significant part of the leakage in the Medicare payment system stems from non-compliance errors rather than premeditated fraud. Indeed, one could argue that there is a significant amount of ‘fear’ of the compliance regime, notwithstanding it is not as far reaching or effective as it could or should be in practice.’ (p. 5).⁴

The paper appears to use unsupported rhetoric, e.g. ‘The Australian Medical Association responded reflexively to media coverage of Faux’s work with self-righteous indignation.’ (p. 256).¹ Two detailed analyses of Dr Faux’s thesis indicated there was no substantive evidence that supported claims of fraudulent Medicare billing, and especially of the vast monetary figures quoted in the media.^2,3

The paper concludes with the statement that non-compliance is widespread because ‘[Dr Philip’s report] estimated the annual cost of non-compliant Medicare billing to be A$1.5–3.0 billion’.¹ The paper does not include the caveat to this estimate: ‘It is not possible for me, based on the lack of available data in the system, and the timeframe for this Review, to conduct and provide you with definitive analysis of the extent of non-compliance and fraud in the system’.⁴ The Philip report also warns: ‘It is my strong suggestion to commentators and policymakers that the actual number [total estimated non-compliance] should not be the main subject of debate, attractive as that may seem.’⁴

The paper presents unreferenced assertions, potential logical fallacies, inaccurate representations of referenced material, and unsubstantiated rhetoric. All these faults raise concerns about the conclusions reached. The paper could have been better argued on evidence, leading to substantiated conclusions. More light, and less heat, are needed to address the important issues raised.

Ethics and participant consent

No ethics approval or consent was required as this paper does not involve research with humans or animals.