Anaesthetists hit back after Four Corners and Margaret Faux accuse them of Medicare rorts

Anaesthetists have accused the ABC of tarnishing their reputation and unnecessarily alarming patients after a Four Corners report alleged that most anaesthetists were exaggerating the time involved in spinal surgeries to milk Medicare.

On Monday night, the show aired allegations of “fraud, waste and abuse” of Medicare and private health insurance rebates from nurse-turned-lawyer Dr Margaret Faux (PhD) and UK medical billing company Kirontech.

A previous ABC report alleged that doctors were rorting $8 billion a year from Medicare based on Dr Faux’s analysis, but a Federal Government review did not back up the scale of the alleged rorts.

For the latest episode, six private health insurers provided de-identified data on 23,635 patients who had undergone spinal surgery, mostly spinal fusions and decompressions, between November 2017 and May 2023.

A report by Dr Faux and Kirontech chief medical adviser Dr Simon Peck, commissioned by the show, concluded that 20% of claims — which totalled $640 million — involved fraud, waste or legal “double dipping”.

These included billing for services that were never provided; billing more complex services than were provided; admitting patients to ICU unnecessarily; and “implausible” billing of high-paying items.

In one example, they claimed that 87% of anaesthetists in the data had billed Medicare for more than 1.5 hours of work for surgeries where time spent on fluoroscopy, the real-time imaging procedure, should have been less than one hour.

They also said that 68% of anaethetists billed Medicare for advanced spinal surgery “that was not advanced”.

They said that 10,082 “allegedly advanced” spinal surgeries were billed to Medicare in one year when national hospital data only recorded 3254 spinal fixation surgeries that involved three or more spinal levels.

“The problems we identified were all-pervasive and affect many different areas of billing, which suggests to us that there may be a culture of reckless billing and wasteful resource use, as well as structural enablers in which bad behaviour is able to flourish,” they wrote in their report.

“Our analysis suggests the main perpetrators of the fraud, waste and abuse in this data were surgeons, who drive most of the costs, and anaesthetists.”

But the Australian Society of Anaesthetists (ASA) said Four Corners had caused unnecessary worry among patients based on a misunderstanding of the Medicare items.

*Australian Society of Anaesthetists president Dr Mark Sinclair.*

“For example, the quote of 87% of anaesthetists overstating time appears to be based on a gross misinterpretation of the Medicare items claimed for anaesthesia,” the society said.

“The vast majority of the anaesthesia time claims are likely to be correct.”

In a letter to members, ASA president Dr Mark Sinclair detailed the “clear misinterpretation” of the Medicare item involved in the claim (read his letter below).

The ASA added: “Some of the broad-brush claims made, not by the impacted patients, were inflammatory and try to bring into disrepute the work done by anaesthetists around Australia on a daily basis.”

“This highlights the importance of seeking input from bodies such as the ASA, where there are concerns, before going public with incomplete and potentially inaccurate information.”

The written report by Dr Faux and Dr Peck for Four Corners said fraud, waste and abuse rates in Australia “may be some of the highest in the world given Australia’s fee-for-service payment system is almost completely devoid of controls and is largely unpoliced”.

But the ASA rejected the claim, saying the story overlooked the compliance work done by Medicare and the private health insurers.

“It is extremely frustrating that our reputation has been tarnished by factually incorrect allegations,” Dr Sinclair said.

“These serious allegations of misuse of Medicare funds by our colleagues could have easily been avoided if only the journalists and ‘experts’ quoted had attempted to contact at least one of our representative bodies for comment.”

The ASA president’s letter to members

As ASA members will be aware, the ABC’s Four Corners program televised an episode on Monday, 8 April, and posted an accompanying online article covering a number of issues regarding surgical procedures for patients suffering from chronic pain — in particular, spinal surgery.

As anaesthetists, including many of us practising pain medicine, we are, of course, extremely sympathetic towards patients suffering from chronic pain in any form.

Even more so for patients who have suffered complications from interventional procedures aimed at relieving their pain.

However, the program also aired concerns about anaesthetists’ billing practices.

Specifically, it was alleged that anaesthetists were overbilling Medicare items for anaesthesia time by significantly overstating the time taken for surgery.

The online version of the program listed the Medicare items claimed for more than 100 cases of spinal surgery.

A series of these cases involved surgical claims for item 60506 (fluoroscopy, less than one hour).

The story noted that, in all of these cases, the anaesthesia time claimed was substantially longer than one hour, noting that “nearly 87% of anaesthetists billed more than 1.5 hours for a surgery with a fluoroscopy time of less than an hour”.

The accusation of misallocation of Medicare funds is based on a clear misinterpretation of the series of Medicare items claimed.

In all of these “fluoroscopy” cases mentioned, surgical items from group T8, subgroup 17 (spinal surgery) were claimed (eg, items 51011, 51012 for spinal decompression; 51021 for internal fixation).

Fluoroscopic guidance was, of course, only one small aspect of these major open spinal procedures.

In virtually all cases, the anaesthesia time claims for these major procedures — likely of several hours or more in duration — would have been correct.

It is possible that the surgeons could have claimed item 60509 (fluoroscopy, procedure over one hour), but these nuances are nothing to do with the anaesthetist, who has no say over what surgical items are claimed.

If any anaesthesia claims remain of “concern” (which would be a tiny minority), both the Department of Health and Aged Care and the private health insurers have the ability to look into this further by liaising with the doctor(s) involved and/or examining the hospital records…

These serious allegations of misuse of Medicare funds by our colleagues could have easily been avoided if only the journalists and “experts” quoted had attempted to contact at least one of our representative bodies for comment.

It is extremely frustrating that our reputation has been tarnished by factually incorrect allegations.

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