‘Red flags’: How to check if you’ve been a victim of a medical bill ‘double dip’
By Melissa Cunningham and Henrietta Cook
Australians who have had surgery in private hospitals are being urged to scour their medical invoices and specialist doctors’ bills for “red flags” showing they have been charged hidden fees outside their health funds or Medicare.
The call comes after The Age revealed allegations against dozens of anaesthetists and surgeons on Victoria’s Mornington Peninsula, contained in a damning confidential whistleblower complaint seen by this masthead. The complaint accuses them of systematic fraud, double-dipping and pocketing off-the-book fees.
Thousands of Australians who have had surgery in private hospitals are being urged to scour their medical bills for ‘red flags’ indicating they have been charged fees outside their health funds or Medicare.Credit: iStock
The complaint centres on allegations that a group of doctors has been charging patients hidden out-of-pocket costs up to $5000 – disguised as booking or administrative fees – for personal financial gain. At the same time, the specialists were purporting to participate in no-gap-fee schemes with health insurers.
The allegations are primarily against a group of anaesthetists and surgeons, but also involve an obstetrician and a gastroenterologist.
Private Healthcare Australia (PHA), a group that represents insurers, is aware of the allegations against nearly 50 doctors in one part of Victoria – stoking fears that the problem is more widespread.
How to check if you’ve been billed incorrectly under no-gap-fee arrangements
If you have private health insurance, call your health fund to examine your bills and ask questions about whether you should be paying out-of-pocket fees or not. They can help you ask the right questions of your provider. If your Medicare records show you were bulk-billed when you were charged a fee, report it to Medicare.
Insurers nationwide are now scrambling to probe the claims of overbilling. The federal government’s Benefits Integrity Division – which investigates claims of health and Medicare fraud – is also investigating.
The federal regulator probe is looking into allegations the doctors bulk-billed their services and pocketed rebates from Medicare, while also charging individual patients for services such as consultations. Bulk-billing and charging a separate gap fee for the same service is illegal.
Separately, under no-gap-fee arrangements in Australia, specialists such as anaesthetists and surgeons receive higher rebates from private health insurance funds if they sign a contract agreeing not to charge a gap fee. The whistleblower alleges the specialists signed these agreements and were in breach of those contracts.
PHA chief executive Rachel David has urged Australians to examine their medical bills for any service not attached to a Medicare item or for statements on bills labelled as “booking” or “administrative” fees.
“If it says that it’s a separate fee that Medicare or the health insurance fund won’t pay, that is a red flag,” David said.
“I would suggest that the first thing that the person does is call their health fund to ask what it means.”
PHA says health insurers have been preparing for an influx of calls from concerned or confused customers trying to determine if they have been overcharged.
Regarding Medicare overbilling, David urged patients to check their claims history on Medicare via their MyGov account. This details what services have been charged to Medicare.
“You want to make sure that that’s matched up with the services that you actually received,” David said.
David said that when a service has been bulk-billed, consumers should not be charged anything extra for that consultation.
“If you have been charged extra then that is against the law, and you need to contact Medicare to notify them,” she said.
If patients believe they have been a victim of fraud, they should report it to Medicare.
David said PHA had heard distressing accounts from people who had been told on the day of their surgery that they would be stung thousands extra in additional fees they were unaware of.
Private Healthcare Australia chief executive Rachel David
This includes instances where a specialist has added an assistant without telling a patient in advance.
“We’ve been told some absolutely terrible stories,” she said.
“Raising a charge while a patient is under duress is unacceptable … if a patient challenged that under consumer laws I think they probably win.”
PHA said one survey by a major health fund recently found about 31 per cent of its more than 4000 members had potentially been ripped off after paying a fee, despite no-gap arrangements.
The health fund is still working through the cases to determine the extent of overbilling.
According to the whistleblower complaint, during her employment at a Mornington Peninsula medical clinic – which spanned a decade – about 90 per cent of patients were stung with out-of-pocket costs, despite the no-gap-fee arrangements.
These hidden fees ranged from $500 to $5000, she alleged.
“I brought this concern up to my superior, who told me not to worry because they have been doing this for more than 10 years and everyone including the specialist surgeons we look after are doing it. ‘It can’t be wrong if anyone is doing it!’” the whistleblower, who is not identified, wrote in the confidential document seen by The Age.
How to report potential fraud to Medicare:
- Complete the Government’s health provider fraud tip-off form
- Call the national fraud hotline – 1800 829 403 or the Benefits Integrity Hotline1800 314 808
- Email ReportFraudorCorruption@health.gov.au
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