Govt proposes Medicare data matching scheme for fraud crackdown

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Govt proposes Medicare data matching scheme for fraud crackdown

Could source data from private health insurers.

The Department of Health is set to expand its data matching activities to better detect fraudulent or incorrect Medicare claims under proposed new laws that would make it possible to pull data from private health insurers for compliance purposes.

But unlike Service Australia’s controversial robodebt program, the department has ruled out using the changes to introduce any automation or perform any compliance activity without human oversight.

Draft laws released for consultation late on Monday are aimed at improving the existing Medicare compliance program by introducing a new “scheme of data matching for permitted Medicare compliance purposes”.

Around 1 percent of the $37 billion handed out through Medicare and other health services claims each year are estimated to be fraudulent, with up to a further 4 percent falling into what the department labels “occasional or inadvertent non-compliance”.

The department’s existing compliance program uses “tip-offs and data analysis of existing Medicare datasets” to identify fraud and incorrect claims.

But while these mechanisms are a “highly valuable source of information”, they are “limited” and the department wants to identify and recover a “greater percentage of incorrectly paid benefits”.

The proposed changes would give the department unrestricted freedom to access Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data that is currently accessible only in “narrow circumstances”.

“The proposed legislation will exclude data matching from this restriction when the matching is undertaken for specified Medicare compliance purposes,” the consultation paper states.

Access to data from the My Health Record would, however, be restricted to the department, though much of this data is also available through the MBS and PBS datasets.

The proposed changes would also allow “certain information” to be disclosed to federal government agencies for both Medicare compliance purposes and to “assist them in performing their functions”.

This data could be sourced from the Department of Vertans’ Affairs, Department of Home Affairs, Australian Health Practitioner Regulation Agency and the Therapeutic Goods Administration.

Private Health Insurers could also provide data to the department on a “voluntary basis” for Medicare compliance activities, though Medicare data will not be shared with those insurers.

Not another robodebt

The department was keen to highlight the distinction between its proposed data matching expansion and robodebt, otherwise known as the online compliance intervention program.

That program is currently facing a class action that asserts that “Centrelink had no lawful basis for issuing Debt Notices in a large number of cases”. This follows two court actions mounted by Legal Aid Victoria earlier this year.

Other recent data sharing proposals by the Office of the National Data Commissioner have also sought to distance themselves from robodebt.

The department said its proposed data matching expansion would not change the “prescriptive” nature of the department's existing Medicare compliance process, which “incorporates corporates procedural fairness and review rights”.

“The proposed data matching and sharing arrangement do not expand the powers of the department to conduct compliance activities. Nor do they change the approach taken by the department in conducting its compliance activities,” the consultation paper states.

“The changes focus only on improving the department’s ability to match and share data for the purposes of identifying fraud and incorrect or inappropriate claiming.

“The proposed changes will not authorise the automation of compliance outcomes or raising of debts, and the Department’s compliance officers will continue to follow prescribed and/or legislated compliance processes.”

Consultation on the proposed Health Legislation Amendment (Data-matching) Bill 2019 will close on 11 October.

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