Radiologist to repay nearly $3M for 'unusually high volume' of inappropriate Medicare claims

A radiologist in Australia is in hot water with health officials after it was revealed they had been disregarding referring doctors’ specific procedural requests. 

On multiple occasions, the unnamed provider is believed to have altered referrers’ orders without first consulting them. The “unusually high volume” of Medicare claims submitted for these procedures raised suspicion among health officials, prompting them to look deeper into the circumstances surrounding the exams.  

This revealed that the doctor had frequently changed orders and completed alternate exams or procedures, though they did not provide clinical documentation to justify the changes. 

“The practitioner’s involvement and clinical input into services was often unclear, in many cases when services were performed and reported by other practitioners but signed by the practitioner under review,” a report on the investigation notes. “Where requests were for specific services, often alternative services were provided, and the records did not indicate why the alternative service was provided, or that the requesting practitioner was consulted as would have been required.” 

The provider also signed off on exams as if they were involved in their completion, though an investigation revealed that they did not complete or supervise them. Despite this, the exams were billed under the provider's name, resulting in millions of dollars in reimbursements from Medicare (Australia’s public, universal healthcare is also called Medicare).  

The Professional Services Review in Australia—a government organization that investigates potential inappropriate practices by healthcare providers—determined that the radiologist in question was in the top 1% of providers of services billed as 88 individual Medicare Benefits Schedule items; they also ranked as the top provider of seven additional services. These included the administration of anesthesia during interventional procedures, the use of ultrasound during musculoskeletal procedures/injections, the use of CT during surgical procedures, CT angiography and more.  

The doctor is now being ordered to repay $2.6 million USD back to the Commonwealth. They also will be required to complete counseling and will not be allowed to submit claims for six different services they previously fraudulently bill for during a period of 12 months.