Specialists forcing patients back to GP for fresh referrals to charge higher fees: health industry

Updated

Specialist doctors could be raking in millions of dollars from Medicare by forcing chronically ill patients back to their GP for a fresh referral each year so they can then charge twice the fee.

An ABC investigation has found evidence of widespread concern in the health industry about the billing practices of some specialists, particularly dermatologists, ophthalmologists and cardiologists.

The Royal Australasian College of Physicians, which represents most specialists in Australia, declined to comment and said the issue of referrals was a matter for Medicare.

The Federal Government would not comment on whether specialist doctors are breaching regulations but there is a general concern in the health industry that the practice of routinely seeking a new referral every 12 months is a waste of money.

Some GPs have spoken out about the issue because they believe it is a misuse of patients' time and appointments.

Central to their concerns is the practice of specialists refusing to accept ongoing or "indefinite" referrals. Some specialists only accept "standard" referrals, which expire after 12 months.

How it works Initial attendance (Item 104):

Minimum charge by specialist: $85.55

You get back from Medicare*: $72.75

Specialists charged Medicare in 2012/13: $347, 613, 929



Subsequent attendance (Item 105):

Minimum charge by specialist: $43.00

You get back from Medicare*: $36.55

Specialists charged Medicare in 2012/13: $241, 594, 919

* Out of hospital



Initial attendance (surgery or hospital)

Minimum charge: $150.90

You get back from Medicare: $128.30

Specialists charged Medicare in 2012/13: $272, 558, 459



Subsequent attendance

Minimum charge: $75.50

You get back from Medicare: $64.20

Specialists charged Medicare in 2012/13: $464, 724, 040



Initial attendance (review and management plan)

Minimum charge: $263.90

You get back from Medicare: $224.35

Specialists charged Medicare in 2012/13: $141, 927, 379



Subsequent attendance

Minimum charge: $132.10

You get back from Medicare: $112.30

Specialists charged Medicare in 2012/13: $47, 898, 494



Total specialists charged Medicare in 2012/13: $1,516,317,219

It means when a patient returns after 12 months with a new referral, the specialist can bill for another initial consultation, which is double the price of a subsequent consultation.

Ultimately, the taxpayer is billed three times: the double consultation and the visit back to the GP for the new referral.

In 2012-13, specialists charged Medicare more than $1.5 billion for initial and subsequent visits, so specialists could potentially be reaping millions.

Medicare paid $347 million in initial consultations and $241 million on subsequent visits for the 2012-13 period.

GPs say the specialists are only supposed to ask for fresh referrals when a condition changes.

It has angered them at a time when the Government is considering slugging patients a co-payment to see the GP.

The ABC understands it has been a contentious issue between GPs and specialists for many years since guidelines changed to allow the writing of indefinite referrals.

Doctors speak out

Melbourne GP Owen Harris is part of a busy practice in St Kilda. He gets annoyed when he has written a patient an ongoing referral only to see them back at his desk 12 months later requesting a fresh one.

He says it wastes an appointment other patients could use.

"I think some specialists are being a bit greedy here and billing Medicare rather than following the requirements," he said.

"It's a waste of patients' time, the GP's time, and certainly Medicare's money."

Dr Harris emphasised it was not all specialists but said the practice was widespread, and particularly prevalent at busy city clinics where doctor turnover is high.

"Medicare is a difficult and complex system," he said.

"Patients can't possibly understand all the complexities. If they're told by the clinic you must bring a new referral then they're simply following that advice without knowing whether or not that's true."

Patients can't possibly understand all the complexities ... if they're told by the clinic you must bring a new referral then they're simply following that advice without knowing whether or not that's true. GP Dr Owen Harris

His concerns have been backed by the Royal Australian College of General Practitioners, who said they were aware of the issue and it was one that needed to be examined.

President Dr Liz Marles says it is common for a melanoma patient to return each year for a referral to a dermatologist for a skin check.

"This is an area that could certainly be explored in terms of increasing efficiency for the patient, the GP and the specialist to make sure we're getting value for money," she said.

Dr Marles says some GPs favour 12-month referrals so they can keep track of patients and hear back from specialists.

However she says specialists should be keeping GPs in the loop regardless of referrals.

The Australian Healthcare and Hospitals Association is also concerned given discussions about co-payments.

Chief executive Alison Verhoeven says it is one of the many anomalies in the health system costing money.

"This is an issue of governance," she said. "It would be helpful if there were better guidelines."

Patients critical of referral process

Melbourne man Peter Barton has an eye condition that requires timely treatment when it recurs intermittently.

His specialist has asked that he return to the practice each time it recurs.

"I just don't understand that at a time when I need to see the specialist, where they want me to see them I've got to do this side trip to the GP first," he said.

"It would be an hour-and-a-half round trip to the GP, on top of the time away at the actual specialist, it almost doubles the time for me to get my eye sorted. It's frustrating."

Debate over whether approach breaks the rules

Dr Harris says the Medicare rules are clear and that specialists are breaking them.

"There's no reason for that to be happening and it isn't something that should continue," he said.

But a senior health industry source has told the ABC the laws and guidelines around the referral billing practices are actually quite vague.

"It all depends on the specific interpretation of very general rules," they said.

"The spirit of the thing is a single course of treatment."

A spokeswoman for the Department of Human Services did not comment on whether specialists were in breach of rules by refusing to accept indefinite referrals but said they monitor doctors over Medicare billing rates.

"A single course of treatment involves an initial attendance by a specialist and the continuing management [of that condition] until the patient is referred back to the referring practitioner," she said.

"The issuing of a new referral does not necessarily mean a new course of treatment."

Do you know more? Contact investigations@abc.net.au

Topics: health-policy, health-administration, health, federal-government, government-and-politics, australia

First posted