Union says 'billions down the drain' in Medicare fraud

The Advertiser

02-07-2025

Overcharging on medical bills and rorting the public health system is costing taxpayers up to $5000 a minute, adding up to billions being wasted yearly, the Health Service Union says.
The union's calculations are based on previous analyses, such as the government-commissioned Independent Review of Medicare Integrity and Compliance in 2023.
They estimated fraud and non-compliance rates to range from five-to-30 per cent with a maximum $10 billion cited as a figure that "cannot be definitively disproven, because there is no effective system to measure fraud and non-compliant billing in the first place".
In a report published on Wednesday, the union found about 60 per cent of medical professionals referred to Professional Services Review (PSR), which investigates cases of Medicare-related "inappropriate practices", in 2024 were GPs.
"Billions of taxpayer dollars are being siphoned away from healthcare through fraudulent Medicare billing," HSU NSW Secretary Gerard Hayes said.
"It's got to stop. Government and regulators have to hold people to account."
"This is public money. Medicare has to be delivering for all of the community not just a certain few."
The union said upcoding was a common fraud tactic, with medical practitioners inflating consultation times to increase reimbursements.
Nearly two thirds of PSR case outcomes in 2024 involved upcoding, while 38 per cent involved incorrect use of GP management plan and/or team care arrangement item numbers.
AAP has sought comment from the Royal Australian College of General Practitioners about the union's findings.
The union, which represents more than 50,000 members across public and private hospitals as well as in other sectors such aged care and pathology, also surveyed 110 healthcare workers in billing, finance, and compliance.
Survey respondents reported witnessing doctors billing for services they did not provide, unnecessary procedures performed purely for billing purposes and systematic manipulation of billing codes to inflate Medicare claims.
One-in-three healthcare workers said they had witnessed or suspected improper billing practices but only 17 per cent understood how to report Medicare fraud.
Half of those surveyed said they faced pressure to maximise profit from Medicare billing and more than 93 per cent of healthcare workers said they were too afraid to report fraud because of fears of retaliation.
The union also pointed the finger at the medical doctors' group, the Australian Medical Association (AMA) for deflecting and resisting meaningful oversight.
"Too many practitioners treat Medicare as an unlimited funding source, structuring their operations around maximising claims rather than responsible spending of public funds or optimising patient care," the 28-page-report published Wednesday said.
The AMA has been contacted for comment."Every dollar lost to Medicare fraud is a dollar taken from hospitals and the most vulnerable Australians who rely on our public health system," Mr Hayes said.
AAP has approached federal Health Minister Mark Butler for comment.
Overcharging on medical bills and rorting the public health system is costing taxpayers up to $5000 a minute, adding up to billions being wasted yearly, the Health Service Union says.
The union's calculations are based on previous analyses, such as the government-commissioned Independent Review of Medicare Integrity and Compliance in 2023.
They estimated fraud and non-compliance rates to range from five-to-30 per cent with a maximum $10 billion cited as a figure that "cannot be definitively disproven, because there is no effective system to measure fraud and non-compliant billing in the first place".
In a report published on Wednesday, the union found about 60 per cent of medical professionals referred to Professional Services Review (PSR), which investigates cases of Medicare-related "inappropriate practices", in 2024 were GPs.
"Billions of taxpayer dollars are being siphoned away from healthcare through fraudulent Medicare billing," HSU NSW Secretary Gerard Hayes said.
"It's got to stop. Government and regulators have to hold people to account."
"This is public money. Medicare has to be delivering for all of the community not just a certain few."
The union said upcoding was a common fraud tactic, with medical practitioners inflating consultation times to increase reimbursements.
Nearly two thirds of PSR case outcomes in 2024 involved upcoding, while 38 per cent involved incorrect use of GP management plan and/or team care arrangement item numbers.
AAP has sought comment from the Royal Australian College of General Practitioners about the union's findings.
The union, which represents more than 50,000 members across public and private hospitals as well as in other sectors such aged care and pathology, also surveyed 110 healthcare workers in billing, finance, and compliance.
Survey respondents reported witnessing doctors billing for services they did not provide, unnecessary procedures performed purely for billing purposes and systematic manipulation of billing codes to inflate Medicare claims.
One-in-three healthcare workers said they had witnessed or suspected improper billing practices but only 17 per cent understood how to report Medicare fraud.
Half of those surveyed said they faced pressure to maximise profit from Medicare billing and more than 93 per cent of healthcare workers said they were too afraid to report fraud because of fears of retaliation.
The union also pointed the finger at the medical doctors' group, the Australian Medical Association (AMA) for deflecting and resisting meaningful oversight.
"Too many practitioners treat Medicare as an unlimited funding source, structuring their operations around maximising claims rather than responsible spending of public funds or optimising patient care," the 28-page-report published Wednesday said.
The AMA has been contacted for comment."Every dollar lost to Medicare fraud is a dollar taken from hospitals and the most vulnerable Australians who rely on our public health system," Mr Hayes said.
AAP has approached federal Health Minister Mark Butler for comment.
Overcharging on medical bills and rorting the public health system is costing taxpayers up to $5000 a minute, adding up to billions being wasted yearly, the Health Service Union says.
The union's calculations are based on previous analyses, such as the government-commissioned Independent Review of Medicare Integrity and Compliance in 2023.
They estimated fraud and non-compliance rates to range from five-to-30 per cent with a maximum $10 billion cited as a figure that "cannot be definitively disproven, because there is no effective system to measure fraud and non-compliant billing in the first place".
In a report published on Wednesday, the union found about 60 per cent of medical professionals referred to Professional Services Review (PSR), which investigates cases of Medicare-related "inappropriate practices", in 2024 were GPs.
"Billions of taxpayer dollars are being siphoned away from healthcare through fraudulent Medicare billing," HSU NSW Secretary Gerard Hayes said.
"It's got to stop. Government and regulators have to hold people to account."
"This is public money. Medicare has to be delivering for all of the community not just a certain few."
The union said upcoding was a common fraud tactic, with medical practitioners inflating consultation times to increase reimbursements.
Nearly two thirds of PSR case outcomes in 2024 involved upcoding, while 38 per cent involved incorrect use of GP management plan and/or team care arrangement item numbers.
AAP has sought comment from the Royal Australian College of General Practitioners about the union's findings.
The union, which represents more than 50,000 members across public and private hospitals as well as in other sectors such aged care and pathology, also surveyed 110 healthcare workers in billing, finance, and compliance.
Survey respondents reported witnessing doctors billing for services they did not provide, unnecessary procedures performed purely for billing purposes and systematic manipulation of billing codes to inflate Medicare claims.
One-in-three healthcare workers said they had witnessed or suspected improper billing practices but only 17 per cent understood how to report Medicare fraud.
Half of those surveyed said they faced pressure to maximise profit from Medicare billing and more than 93 per cent of healthcare workers said they were too afraid to report fraud because of fears of retaliation.
The union also pointed the finger at the medical doctors' group, the Australian Medical Association (AMA) for deflecting and resisting meaningful oversight.
"Too many practitioners treat Medicare as an unlimited funding source, structuring their operations around maximising claims rather than responsible spending of public funds or optimising patient care," the 28-page-report published Wednesday said.
The AMA has been contacted for comment."Every dollar lost to Medicare fraud is a dollar taken from hospitals and the most vulnerable Australians who rely on our public health system," Mr Hayes said.
AAP has approached federal Health Minister Mark Butler for comment.
Overcharging on medical bills and rorting the public health system is costing taxpayers up to $5000 a minute, adding up to billions being wasted yearly, the Health Service Union says.
The union's calculations are based on previous analyses, such as the government-commissioned Independent Review of Medicare Integrity and Compliance in 2023.
They estimated fraud and non-compliance rates to range from five-to-30 per cent with a maximum $10 billion cited as a figure that "cannot be definitively disproven, because there is no effective system to measure fraud and non-compliant billing in the first place".
In a report published on Wednesday, the union found about 60 per cent of medical professionals referred to Professional Services Review (PSR), which investigates cases of Medicare-related "inappropriate practices", in 2024 were GPs.
"Billions of taxpayer dollars are being siphoned away from healthcare through fraudulent Medicare billing," HSU NSW Secretary Gerard Hayes said.
"It's got to stop. Government and regulators have to hold people to account."
"This is public money. Medicare has to be delivering for all of the community not just a certain few."
The union said upcoding was a common fraud tactic, with medical practitioners inflating consultation times to increase reimbursements.
Nearly two thirds of PSR case outcomes in 2024 involved upcoding, while 38 per cent involved incorrect use of GP management plan and/or team care arrangement item numbers.
AAP has sought comment from the Royal Australian College of General Practitioners about the union's findings.
The union, which represents more than 50,000 members across public and private hospitals as well as in other sectors such aged care and pathology, also surveyed 110 healthcare workers in billing, finance, and compliance.
Survey respondents reported witnessing doctors billing for services they did not provide, unnecessary procedures performed purely for billing purposes and systematic manipulation of billing codes to inflate Medicare claims.
One-in-three healthcare workers said they had witnessed or suspected improper billing practices but only 17 per cent understood how to report Medicare fraud.
Half of those surveyed said they faced pressure to maximise profit from Medicare billing and more than 93 per cent of healthcare workers said they were too afraid to report fraud because of fears of retaliation.
The union also pointed the finger at the medical doctors' group, the Australian Medical Association (AMA) for deflecting and resisting meaningful oversight.
"Too many practitioners treat Medicare as an unlimited funding source, structuring their operations around maximising claims rather than responsible spending of public funds or optimising patient care," the 28-page-report published Wednesday said.
The AMA has been contacted for comment."Every dollar lost to Medicare fraud is a dollar taken from hospitals and the most vulnerable Australians who rely on our public health system," Mr Hayes said.
AAP has approached federal Health Minister Mark Butler for comment.