Some doctors overbilling medicare without penalty

Some New Brunswick doctors are overbilling medicare and not facing any penalties, according to the auditor general.

Sixteen doctors were paid more than $1 million in 2011, more than double the amount budgeted by the Department of Health for the average annual earnings of a specialist, Kim MacPherson states in her 2012 report, released on Tuesday.

In some cases, doctors double billed, charging both Medicare and the province's WorkSafeNB for the same service, the province's chief financial watchdog found.

There are no deterrents to wrongful billing, said MacPherson.

'The observations on payments to doctors are intended to highlight unusual items that, in our professional opinion as auditors, may warrant further investigation by the department.' —Auditor General Kim MacPherson

She is calling on the department to enforce existing legislation and have clearly documented procedures.

"There should be consequences when a doctor repeatedly submits inappropriate claims," she said.

Although the Medicare Act authorizes the department to revoke a doctor's billing privileges for the offence, it has never done so, MacPherson found.

The department does not issue fines or charge any interest either, she said.

Other findings of the report include:

• Only a portion of payments to doctors are audited
• Monitoring is "inadequate"
• Recovery of overpayments is low
• Public reporting of remuneration is incomplete and misleading

"The observations on payments to doctors are intended to highlight unusual items that, in our professional opinion as auditors, may warrant further investigation by the department," the report said.

Ophthalmologist paid nearly $1.7M

Medicare payments to some doctors appear high, compared to budget estimates, MacPherson said, noting 16 doctors were paid more than $1 million each in 2011.

One ophthalmologist received the most at nearly $1.7 million, which is almost $1 million more than the average for that specialty.

The top-billing general practitioner was paid $1.3 million, which is far higher than the average $255,000 for these doctors.

MacPherson also singles out radiologists, five of whom billed Medicare more than $1 million. She recommends the health department take "immediate action" to require radiologists to submit information on patients, diagnosis and treatment with their bills.

There were 219 doctors paid more than $500,000, while 826 received more than $300,000.

By comparison, the Department of Health had budgeted for general practitioners to earn an estimated $291,418 annually, while the average specialist would earn an estimated $420,977 each year.

"Given this, we believe remuneration greater than these figures should be considered high," the report states.

"We believe the department should identify doctors with high medicare earnings and doctors with earnings significantly higher than their specialty average; their earnings should be reviewed to determine reasonableness and audited if suspect."

Lack of auditing, monitoring

Only 53 per cent of medicare payments to doctors are currently audited, said MacPherson.

"The fee-for-service payments system is based upon the honour system," with only a portion of those payments audited, she said.

Meanwhile, radiology, salary and sessional payments are not audited at all.

"We believe although it may be more difficult to audit some types of medicare payments, given the magnitude of the payments involved, alternate audit methods should be pursued so all types of payments (100 per cent) are included in the audit population," the report said.

Monitoring of payments also needs improvement, said MacPherson. As it stands, there is no monitoring of radiologist remuneration and monitoring of fee-for-service payments, and payments to salaried doctors is "lacking," she said.

Make earnings public

MacPherson also recommends the Department of Health publicly report the total remuneration for each doctor to allow for public scrutiny and proper accountability — even if it requires changes to legislation.

"Medicare has a huge impact on the lives of all New Brunswickers," she said.

Medicare expenditures in 2011 were $553 million, representing 22.3 per cent of the Department of Health's expenditures.

The average annual recovery for inappropriate payments between the fiscal years 2002 and 2011 was $72,581, she said. The Medicare Audit Plan 2012-13 projects recoveries of $3.21 million.