Thousands of patients who had surgery in private hospitals may have been overcharged by specialist doctors, according to allegations of fraud by Private Healthcare Australia.
The group claims almost 50 specialist doctors in Victoria systematically defrauded patients, health funds and Medicare for personal financial gain.
The specialists are mostly anaesthetists and surgeons, as well as an obstetrician and gastroenterologist. They have been accused of charging patients extra fees of up to $5000 while purporting to participate in ‘no gap fee’ arrangements with health insurers.
They have also been accused of telling Medicare they were bulk billing patients while charging fees labelled ‘booking fees’ or ‘administrative fees.’
While the doctors facing accusations are based in Victoria, health insurers are urging people across the country to check their medical bills as there are concerns the issue could be wider spread.
They said patients should check to see if they were charged a fee while being bulk-billed or treated under a no-gap fee arrangement.
Chief executive of Private Healthcare Australia Dr Rachel David said patients should call their health insurer to check they have been billed correctly.
“These allegations are deeply disturbing because of the trust patients put in their specialist doctors. When you seek the help of a surgeon and an anaesthetist you are typically at your most vulnerable. You do not expect them to be financially exploiting you at the same time,” she said.
“There is a huge power imbalance between patients and doctors. We know many consumers do not understand their medical bills, which means most people wouldn’t know if they were getting charged inappropriate fees or not.”
Dr David warned allegations of ‘shadow billing’ suggested specialist doctors were billing consumers unknown amounts of money under the counter and not reporting that income to other payers, including Medicare and insurers so it could be publicly recorded.
“Unfortunately, this means we cannot trust our Medicare statistics, our APRA data, and the Government’s Medical Cost Finder website, which reports how many doctors charge out-of-pocket fees for procedures, as well as what the average out-of-pocket cost is for those procedures,” she said.
“Medicare needs to urgently investigate these allegations to ensure taxpayers are not footing the bill for industrial scale fraud in our private health system.”
It comes as Australian Bureau of Statistics data on patient experience revealed 11% of Australians are not seeing a specialist doctor, or they are delaying appointments, due to cost.
Medicare data also suggests seeing a specialist is becoming more expensive, with 29% of consultations with specialist doctors in 2023/24 bulk billed – down from 30% the previous year.
The ABS data also show the proportion of people reporting cost as a reason they have delayed or avoided seeing a GP has increased from 7% to 8.8%.
In addition, the proportion of people who said cost was the main reason for not seeing an after-hours GP when needed increased from 4.4% in 2022/23 to 6.2% in 2023/24.
Women, young people, those on lower income and patients with long-term health conditions were more likely to delay care, or not access care, due to costs.
RACGP president Dr Nicole Higgins warned some patients were beginning to see preventative care as optional as they look to save money.
“The ABS data shows that more people are delaying health care because they simply can’t afford it. We know that when people put off care, they get sicker and it puts more strain on our hospitals and the whole health system,” she said.
“We’re also seeing young people starting to treat preventative care as optional, because it’s a cost they can’t afford, which is concerning. The survey showed that 15.4% of people aged 25-34 delayed GP care due to cost in 2023-24, up from 10.2% in the previous year.”