Data matching Bill to clamp down on inappropriate billing

The Federal Government wants to improve Medicare compliance by instituting changes to the National Health Act and the Health Insurance Act that will allow Health Department auditors to match and share data across the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, Therapeutic Goods Administration and more.

The proposed Health Legislation Amendment (Data-matching) Bill 2019 has been designed to bolster the Department’s ability to analyse Medicare data to identify non-compliance, leaving it less reliant on tip-offs for detecting fraud and incorrect claiming.

Currently, section 135AA of the National Health Act 1953 and associated National Health (Privacy) Rules 2018 only permit matching of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data in narrow circumstances.

The Bill will broaden the auditing process by authorising matching of the following datasets:

  • Medicare Benefits Schedule
  • Pharmaceutical Benefits Schedule
  • Therapeutic goods information
  • Registration information from the Australian Health Practitioner Regulation Agency (AHPRA)
  • Department of Veterans Affairs programs 
  • Information voluntarily provided by private health insurers
  • any other information that can be lawfully provided to the Chief Executive Medicare, such as information about whether a person is in Australia at the time of claimed service
  • held by the Chief Executive Medicare for the purposes of a Medicare program.

The Bill will not, however, allow the department to access My Health Record data.

The proposed legislation defines its scope as being “only Medicare compliance related purposes”, such as:

  • detecting Medicare fraud
  • detecting incorrect claiming 
  • detecting inappropriate practice by health providers.

According to the Bill’s consultation guide, released on 23 September 2019, the changes “focus only on improving the Department’s ability to match and share data for the purposes of identifying fraud and incorrect or inappropriate claiming”.

Detecting bad behaviour 

The Bill enables the matching of specific data-sets with other prescribed Australian Government agencies in order to: 

  • identify whether a person may have engaged in Medicare fraud or incorrect claiming
  • recover overpayments of benefits due to fraud or incorrect claiming under a Medicare program
  • detect or investigate contraventions of a law in relation to Medicare
  • detect or investigate whether a healthcare provider may have engaged in inappropriate practice
  • analyse services and benefits
  • educate healthcare providers about Medicare program requirements.

Data matching in action

  • Matching MBS and TGA data will assist with identifying where health providers have claimed MBS benefits for medical devices which are not eligible for a Medicare rebate.
  • Matching MBS data and DVA data will assist with the detection of instances when the same health service is billed to the MBS and DVA.
  • AHPRA registration data will be matched with MBS or PBS data to assist with identifying where a practitioner may be practising or prescribing outside AHPRA restrictions or registration conditions.
  • Information from private health insurers will be matched with MBS data to assist in identifying when services may be claimed incorrectly or inappropriately within private hospitals.

Addressing privacy issues

Prior to the consultation period start date the Bill underwent a comprehensive Privacy Impact Assessment by an external assessor.  Where non-compliances were noted recommendations have been made to address and rectify issues to achieve compliance with the Privacy principles and the Department of Health has agreed to action the 12 recommendations made.

The ASO view

ASO President Dr Peter Sumich says the Society is supportive of the Bill.

“The Health Department and MBS Review have proposed significant investment in sophisticated data matching programmes which will make misuse of MBS items easily detectable,” Dr Sumich said.

“We strongly support this.”

Public consultation over the Bill closed on 11 October 2019. The Federal Government is currently considering submissions received.

Fast facts

  • In 2018-19, the Australian Government spent $37.1 billion on Medicare and other health services funded by the Department of Veterans’ Affairs (DVA).
  • Just one half of a percent of Medicare payments being fraudulently, incorrectly or inappropriately billed equals around $180 million of health benefits lost.

Source: Australian Government, Department of Health

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