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Thursday / June 20.
HomeminewsMedicare Fraud Case Highlights Need for Compliance

Medicare Fraud Case Highlights Need for Compliance

The recent case of an optometry practice owner who defrauded Medicare by more than AU$4 million has highlighted the need for optometrists to closely monitor use of their Medicare provider number and use Medicare items appropriately.

Tisha Thi Thi Phan, practice owner of I Design Optical stores in Macquarie Fields and Minto, New South Wales, was jailed for a maximum five years (with a non-parole period of three years) after pleading “guilty to obtaining a financial advantage by deception and attempting to obtain a financial advantage by deception”.

Optometrists are at personal risk if they bill inappropriately, even if this was on the advice of their employer, manager, or peer

Ms Phan is not an optometrist, and therefore does not have a Medicare provider number. Instead she used the Medicare provider numbers of six optometrists who worked for her business to submit almost 30,000 claims for over 49,000 optometry services (patient consultations, services relating to contact lenses, and computerised perimetry tests) between 18 October 2013 and March 2015. In the process, she acquired $4,046,671 in Medicare benefits. Almost 12,000 other claims, worth more than $870,000, were submitted but rejected.

PERSONAL RESPONSIBILITY

Simon Hanna, Professional Development and Clinical Policy Manager at Optometry Australia said optometrists are personally responsible for their Medicare provider number and billing decisions.

“It’s important that optometrists recognise that currently, in the eyes of Medicare, they are fully responsible for their billing decisions, including any inappropriate billing…. Optometrists are at personal risk if they bill inappropriately, even if this was on the advice of their employer, manager, or peer.

All optometrists should ensure they have a clear understanding of the billing criteria for any item they bill,” he said.

He advised that on 1 July this year, introduction of a Shared Debt Recovery Scheme will enable the Government to hold a practice/organisation responsible for a proportion of debts owed for incorrect billing. This amendment acknowledges that some of the responsibility for ensuring correct billing also rests with the employing organisation.

To protect a Medicare provider number, Mr Hanna recommended optometrists promptly notify Medicare to request the number be closed if they cease working at a practice and are unlikely to return.

“This will alleviate any concerns about inappropriate use or billing against their provider numbers. It has the additional benefit of not allowing practices to bill Private Health Insurance claims against their names and provider numbers.”

He said monitoring use of a Medicare provider number to ensure it is not being used by another person is not straight forward. If concerned, practitioners can contact Medicare to see if any claims have been made against specific provider numbers.

INCREASING FRAUD DETECTION

Mr Hanna said sophisticated data analysis means those who inappropriately use Medicare item and provider numbers are increasingly likely to be caught out.

“Medicare billing patterns have always been monitored and the billing patterns of individual optometrists have been compared with the billing patterns of the profession overall, as a mechanism for identifying potentially non compliant billing. We understand that the Department of Health is now employing increasingly sophisticated data analysis to identify billing behaviours that may indicate non compliant billing and fraudulent behaviour.

“We encourage our members who may be uncertain about the interpretation of a particular Medicare item and when it can be appropriately billed, to consult our Medicare Billing Guide or call our Member Support team,” said Mr Hanna.

PENALTIES ARE HIGH

The cost of misusing Medicare items and provider numbers is high.

“If an optometrist is audited and found to have billed incorrectly they are responsible for the repayment of the full amount of the incorrect benefit paid, and may also be required to pay an administrative penalty,” said Mr Hanna.

“A number of changes have recently been made to the relevant legislation to strengthen the powers that the Department of Health has to recover debts from incorrect claiming. Cases of criminal or fraudulent activity can also be considered for potential criminal prosecution.”