Who’s a Medicare expert? Anyone by law, no one in reality


Written by Margaret Faux – Founder & CEO at Synapse Medical Services, published in Medical Observer, 16th July 2019.

Does experience or education make an expert, or both?

Like knowing exactly when to enter a roundabout, the word ‘expert’ feels imprecise and poorly defined. Paul Keating left school at the age of 14, but went on to be hailed as the world’s best finance minister. Was he an expert economist or just someone with innate economic talent? Is there a difference? I know we need experts because a lack of them led me to a PhD in Medicare claiming and compliance.

It was 2012, Julia Gillard was our Prime Minister, and I perceived in my work as the CEO of a medical billing company that there was a growing Medicare problem no one was talking about. For decades, my Medicare billing questions weren’t able to get straight answers from anyone (including Medicare). Where were the experts? Medicare law is not a recognised legal specialty so there were no lawyer colleagues I could call upon. Even trusted colleagues at the Medical Defence Organisations know little more than me.

In the seven years since I re-entered academia, Medicare hasn’t been out of the spotlight for long, and we seem to be reaching a peak of panic, desperation and fake news about how Medicare works and how to bill correctly. For consumers, the well-meaning media incorrectly reports on this topic constantly. Its latest struggle seems to be the legalities around booking fees, saying such fees are purposely ‘hidden’ when in fact doctors can’t transmit these payments to Medicare. These articles simply confuse consumers further, so we create new problems instead of fixing them.

On the doctor side, ‘experts’ have sprung up everywhere, with increasing numbers of organisations self-declaring as medical billing experts.

While not surprising, it is deeply troubling. There is no national curriculum on Medicare billing and never has been; even Medicare staff learn on the job. Medicare is a complex legal system with criminal sanctions for serious breaches, so perhaps a minimum qualification of a law degree is required by self-anointed experts?

And obviously Medicare is not a medical system of human anatomy, pathology, diagnosis and treatment, so it can’t be a medical degree alone that would qualify you to understand its legal structure, administrative processes, rules and regulations. It’s just nonsense. A doctor can’t declare themselves an expert in pharmacology because they read the drug information leaflet or even regularly prescribe drug A?

Unfortunately, I don’t know the answers. With more than three decades of experience in processing Medicare bills across every medical specialty, over two decades practising law, over a decade of clinical experience and now close to the end of a seven-year PhD, I remain intensely uncomfortable with the word ‘expert’. The learning appears to never end! Just last week, I found a stunning, little, relatively-unheard piece of law, but it has a significant impact on doctor billing.

Public hospitals don’t need to reimburse private rebates when a patient’s status changes back to public. Who knew?!

Despite eschewing the term ‘expert’, I am regularly asked to provide education and training to doctors and hospital staff on medical billing. In this unregulated market I view it as a high-risk activity. Medicare cannot formally endorse any provider of medical billing education, but neither can they stop anyone from providing it. Anyone can currently write educational material on Medicare billing and ask Medicare if it is okay to distribute it. There is no law enabling Medicare to say ‘no’, so their response is always ‘yes’. So I exercise extreme caution when commenting on medical billing and stick tightly to law, facts and evidence.

We are experiencing constantly-changing Medicare rules and high scrutiny right now, and everyone seems to know someone being audited. While well-intended ‘experts’ may trade on an enticing promise that, if General Practitioners do what they’re told, they’ll make more money or pass an audit, it’s worth noting that just as every good doctor knows no two infections are the same, every good lawyer knows no two audits, investigations or cases are the same. Something that started as an audit can quickly turn into something more serious, just like a simple urinary infection can become sepsis.

There are no Medicare ‘experts’, so be careful out there dealing with them. Good luck.


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