‘A great big lie’: researcher disputes government claim that 90% of GP visits are bulk-billed

The Australian government says almost nine out of 10 visits to GP clinics are bulk-billed, but a health insurance researcher says gap fees often aren't recorded, meaning the official data is "a great big lie".

Andrew James*, his wife, and their two children were bulk-billed for 15-minute appointments at their Sydney GP clinic for three years with their Medicare records showing they paid "$0".

However, at every appointment, James and his family were charged a $35 gap fee as a separate Eftpos transaction.

"There was nothing on our health records capturing this money as an out-of-pocket expense," he said.

"I tried to address it with the clinic, but I did not push too hard because there are not many places to go near me and the doctors there are very good. In their defence, they have bulk-billed my flu shot since Covid because of my asthma, and sometimes they wouldn't charge the gap for the kids, but not that often."

In GP appointments alone, the family was paying about $300 a year despite the official $0 figure on their records.

Dr Margaret Faux, a solicitor and health insurance law academic recently published her PhD on Medicare claiming and compliance. She says the experience of James and his family demonstrates why the government's bulk-billing data has been drastically overinflated and "is a great big lie".

"It is an example of a very common problem that completely skews the bulk-billing statistics," Faux, who is also a registered nurse, said.

This type of billing is illegal, Faux said, but her PhD research showed it was rife. Faux is the founder and CEO of Synapse Medical, which educates health providers about how to bill their patients legally. The Medicare billing system is so complex, she said, that education services like hers were needed.

"The other issue about 'gap fees' not being charged properly is that it blocks patients and their families from reaching safety net thresholds, which are there to lower their out-of-pocket costs," Faux said.

"The safety net only kicks in once you have paid a certain amount out-of-pocket. But if the government doesn't see your out-of-pocket costs, because they are charged on a separate Eftpos transaction, then you don't reach the threshold."

The academic says many clinics do not know they are billing illegally because the practice has become so common. What should happen is that either the patient is bulk-billed and pays no money - or they are charged a private fee, a portion of which is rebated by Medicare directly into the patient's bank account. The clinic James attends now does this.

But many clinics are claiming the rebate for themselves and charging the patient a separate gap.

Faux said everyone should log in to Medicare and view their records and look at the "cost to claimant" column. If a cost in that column says $0 but you paid for the service and were left out-of-pocket something was likely wrong, she said.

"This is a massive problem that I see or hear about very often in my daily work, and is why the bulk-billing statistics are essentially rubbish," she said.

In March, Hunt issued a press release stating: "Essential medical care is more affordable than ever before with the number of Australians receiving essential medical care with no out-of-pocket cost continuing to rise."

Out-of-pocket health costs are a key issue for patients, the chief executive of the Consumers Health Forum (CHF), Leanne Wells, says.

"We have been sceptical for some time about claims of high rates of bulk billing," she said. "The rates don't reflect people's experience when they find it hard or impossible to find a bulk-billing doctor."

To address rising out-of-pocket health costs, medical bodies including the Australian Medical Association and the Royal College of General Practitioners argue Medicare rebates to patients need to increase.

The AMA president, Dr Omar Khorshid, said rebate freezes under both major parties meant the rate of growth in a patient's Medicare rebate was less than inflation and wages growth.

"In real terms, general practice is being asked to do more with less and this is impacting practice viability and access to services for patients," he said.

The CHF agrees increasing rebates would boost primary health care. "If the rebate was raised it could encourage more realistic bulk billing," Wells said.

Neither the Coalition nor Labor are promising to increase rebates. Faux believes they should, but also argues until the problem of non-compliant billing and a dysfunctional Medicare system is addressed, a rebate rise would do little to reduce out-of-pocket costs.

"Say we put the rebate up from $39 to $40. Do you honestly think the GPs who are billing incorrectly and charging, for example, a $35 'gap' are going to reduce that amount to $34? Obviously not. The GP is just going to pocket it. That's not going to alleviate the out-of-cost burden on this consumer.

"So until we fix the broken, non-compliant business model, we can't increase the rebate."

Faux said wrongful billing was not detected by government compliance officers because it was so common and didn't show up on Medicare records as an outlier.

Anthony Scott, a professor of health economics at the University of Melbourne, agrees with Faux that bulk-billing statistics are inaccurate. He praised her work on billing compliance saying she was the first person to tackle it in-depth.

Scott said out-of-pocket health care costs were rising faster than wages and faster than other consumer prices - and neither of the major parties had offered significant policies to address the issue.

Adding to rising GP costs are specialist expenses, where there is scant transparency around out-of-pocket costs and fees. Scott said it can be more difficult to "shop around" for a specialist appointment because wait lists are long, referrals are hard to get, and appointments are scarce.

"Specialists are just not touched by any calls for reform," Scott said. This is despite only 35% of specialist consultations being bulk-billed in 2020-21, he said. Less affluent people with more urgent health needs are also affected disproportionately by these fees and forced onto public lists where wait times are longer.

"There's even less oversight and data when it comes to the specialist side of the health care cost debate," Scott said. "In oncology, for example, an increasing proportion of cancer care is being undertaken by the private sector. And when you have cancer, you just want to get rid of it as quickly as possible. You haven't got time to shop around."

*Name changed for privacy reasons

Do you know more? melissa.davey@theguardian.com