This paper is an overview of medical fraud and overservicing that has been associated with Australia’s system of universal health insurance, firstly Medibank and then Medicare. Medibank was introduced without effective mechanisms being implemented to control medical fraud and overservicing. The result has been that since the mid-1970s, health providers, as well as "receptionists, patients, ancillary health-care workers and computer hackers have been able to exploit the system. And they have done so at the individual, syndicate and corporate levels" (Graco: personal communication 14/8/01). The media has followed the many stories that have arisen as a consequence of this. The exposes and scandals led to a public inquiry in the 1980s with public demands for tighter legislative and administrative regulatory frameworks. In response to this, the Joint Public Accounts Committee Inquiry into Medical Fraud and Overservicing was set up. It ran for three and a half years and was the longest running PAC investigation in Australia’s history.

Whistleblowers and unauthorised leakers, firstly in Medibank Private and then in the Department of Health, have been instrumental in communicating information regarding the extent of fraud and overservicing, via journalists, to the public arena. Journalists and their sources have been effective in spearheading change for better fraud control, but undercutting these efforts has been a medical profession resistant to further government control.

The context of the inquiry …this "strife of interests"…

According to Professor Sidney Sax, the medical profession had two major concerns about the introduction of Medibank. It threatened professional autonomy and its central computer database would provide information to governments of the extent of fraud and overservicing (Sax 1984: 192). The medical profession, particularly the AMA would have been glad to be rid of Medibank and in this they were supported by the Coalition. In fact, prior to the 1975 election, Coalition health policy was for the abolition of Medibank and its replacement with compulsory health insurance, with one third government contribution, one third private and one third health insurance (Wooldridge 1991: 5). However, when Malcolm Fraser assumed power in 1975, he retained Medibank out of recognition for its electoral popularity, but he attempted its dismantling through five revisions of the system (Wooldridge 1991; Crichton: 85). His next target was fraud and overservicing and allied to it the problem of the "new and improving technologies which were adding to the cost of health care (Wooldridge 1991: 46). In May 1981, an article appeared in The National Times that argued "a small but increasing number of doctors are engaging in unethical practices for financial gain; indeed the situation has become so blatant that many doctors are now openly discussing the currently fashionable rackets (Hickie 1981: 12). In response to this allegation, the Health Minister, Michael MacKellar, called for a departmental briefing.

John Kelly, Director of the Operations branch of the Department of Health, was given the task of preparing an estimate of the extent of fraud and overservicing to be included in the briefing. However, Department of Health was caught between the demands of accountability to the public purse on the one hand and on the other, not wanting to give offence to the medical profession. Kelly judged that if the estimate was included in the brief it would be deleted by senior management, so what he did was hide the estimate in an attachment to the brief. His assessment was correct. All the paragraphs of the brief were deleted, but the attachment stayed. John Kelly was an unusual whistleblower. He released information that the department would rather not be disclosed, but by including it as an appendix to a departmental briefing he did it in a fashion which was procedurally proper. The information got to the Minister and was forwarded to the AMA. They accepted the figure of $100m lost in fraud and overservicing. It is probably doubtful whether Kelly’s career in the Department of Health could have been salvaged after these events. Even on the first day of the PAC’s hearing the following exchange is indicative of Kelly’s unpopularity with the Department’s senior officers.

Roz Kelly: Have you ever had a (death) threat?

Mr. Kelly: No

Dr. Howells: Except from inside the department

Chairman: Perhaps you should not say that in jest?

Dr. Howells: Sorry?

Chairman: Perhaps you should not say that in jest?

Another whistleblower, Roy Harvey, former head of the data management operations section of Medibank, also gave evidence before the Inquiry. He argued that even using relatively poor quality data, you could identify gross forms of overservicing and fraud. Some of the frauds were crude, for example billing 30 hours a day. When asked how they dealt with sophisticated methods of fraud, he relied that they didn’t come across them because with so few prosecutions, defrauders relied on the "old tried and proven methods" (JCPA, 1982 vol 6: 2261). The reason why there were so few prosecutions was because of the problems associated with presenting evidence of fraud before the courts. A provider might submit false claims for thousands of small amounts, but as each case had to be proven, only a selection of these would be presented in court, but those not presented would not be considered. So the case would look like is a minor aberration, when in fact thousands of dollars would have been involved in the case, and the penalty would be lenient.

Adding further momentum to the PAC inquiry was the activity of unauthorized leakers. Forty-one files relating to medical fraud that had not been investigated by the Victorian branch of the federal Department of Health. These were obtained by the Public Accounts Committee. Chairman, David Connolly announced on the first day that the committee would not be asking any questions in relation to these files. (JCPA vol. 1: 303). In September, an unauthorized source, frustrated with the inability of the Committee to deal with the entrenched problems of the Victorian branch took it upon themselves to leak the files to The Age newspaper in Melbourne. The department was shown to be grossly negligent in dealing with its cases.

The Age newspaper had led the field in its coverage of the PAC inquiry throughout the year. Michael Smith, the editor, said "Medifraud had been a great issue for The Age. The Age had been vigorously following white-collar crime in all areas and was active in following the health debate. Smith denied that The Age was deliberately undermining the Fraser government. He said, "this is a common belief, but a misconception. Any government in decay will do things that deserve kicks. The whistleblowers and leakers get more aggressive in the face of a weakened government. They now have the opportunity to do something that will be effective and make a difference. So that it is not so much the journalists doing the kicking as the sources" (interview Michael Smith 31/1/00).

The inquiry had revealed that the Department of Health was not supporting its own investigative efforts. At the outset of the inquiry the AMA acknowledged the amount lost in fraud and overservicing and the need for an investigation. By the end of the inquiry, it was not prepared to support the government on this issue. In 1984, after a six months long doctors’ strike in NSW and on the eve of a federal election, the federal government agreed that it would disband the fraud and overservicing section of the Department of Health. This agreement was reported in detail in The Canberra Times of 30th November 1984. So after years of the Public Accounts inquiry the government backed down on the issue, but it is hard to tell if the government saw this as a defeat. Here after all was an opportunity to seal off ‘leaks’ to the press, remove the issue from the news agenda and placate the medical profession all at the same time. The fraud and overservicing function was later re-established, with new staff, in the Health Insurance Commission. This act of political expediency was justified by an "independent report" recommending these changes and it also suggested that an aggressive prosecutorial approach be abandoned (Wilson & Grabosky 1986: 163). Some years later, The Bates Report, commissioned by the Health Insurance Commission, confirmed that the move to the commission had meant the loss of the skills base of the previous staff of the fraud and overservicing unit of the Department of Health and that this investigative function had never been successfully integrated into the Health Insurance Commission’s operations (Bates 1992: 2). The machinery of a parliamentary inquiry was no match against the willingness of governments of both persuasions to yield to the medical profession (Wilson & Grabosky 1986: 162). Criminologists, Wilson and Grabosky expressed concern that important recommendations of the inquiry had been ignored, that a key witness before the inquiry had met the usual fate of whistleblowers and had been subjected to personal abuse and organizational pressure and officers of the Department of Health in the area of fraud and overservicing were fighting to retain their positions.

This move entailed the destruction of documents on all cases currently under investigation. Whether this occurred is debatable. In any event, ABC television’s Four Corners was the recipient of documents on a medical entrepreneur, Geoffrey Edelsten. Investigative reporter, Chris Masters discovered in Edelsten an unusual businessman. He had connections to well known crime figures and corrupt police and judging by the number of tattoo removals he was doing it wasn’t possible he was doing all himself. As well as overservicing was his secret war on one of his patients. When he made death threats, unlike the health bureaucrats, Edelsten was prepared to carry them through. It was a great receipe for great television.

Despite Edelsten’s unique decorating touches in his medical clinics – crystal chandeliers, pianos and mink covered examination tables, what was significant here was his championing a new style of medical practice. This meant 24-hour medical clinics, "efficiency" of service and the Macdonalisation of medicine. Such clinics, publicly funded as they are through Medicare, gave the public and the government little control over the volume of services, the nature of the services, the location of the clinics or the patterns of referral (Moore & Tarr, 1988: 5). Traditional medical practices offered opportunities for overservicing but with medical clinics such opportunities were improved by having short consultation times and a high proportion of referrals to specialists and specialist services like pathology. In reference to pathology there were concerns regarding the prevalence of fee splitting and kickbacks. These practices were already prohibited by the terms of the Health Insurance Act but there appeared to be a need for tighter controls against such practices (Moore & Tarr, 1988: 32).

Entrepreneurial medicine was judged by most to add further opportunities to defraud Medicare but economist Jeff Richardson, judged this as the way of the future. He argued that in regard to overservicing "there is only anecdotal evidence that this type of behaviour occurs and there is no evidence from which even the most rudimentary estimates could be made to assess the prevalence and importance of these practices" (1987: 8). He is well satisfied that medical clinics deliver services efficiently but in regard to pathology there are the maximum incentives for abuse with the minimum controls (1987: 12).

With the closure of the fraud and overservicing branch in the Department of Health the government now had the opportunity to institute more effective news management strategies, and deflect unfavorable publicity away from the Health Insurance Commission. And the media was invited to aid the work of publicising the need for more resources and better legislation.

The function of policing fraud and overservicing was now with the Health Insurance Commission’s Professional Review Division and there was slight media coverage until 1990. In a pathology case before the Local Court in Sydney, (Police v. Bacich & Bacich, 3/5/90) the magistrate dismissed a case of medical fraud because the evidence was too complex for a jury to understand (The Age, 4/5/90:1). This was reported by the National Audit Office, which didn’t name the case in question (ANAO No. 17, 1992:14), and Four Corners covered it in its program "Blood Money" (ABC-TV 27/4/92). It named the case but wasn’t in a position discuss the court finding. This case also caught the attention of constitutional lawyers. They noted that the Commonwealth government has limited legislative power over health. In addition the use of complex corporate structures by pathology companies makes the prosecution of cases very difficult (Wheelwright 1994).

For the program makers there was a hope that the program would force improvements in the system. The owner of the pathology company in question sued the ABC for defamation, but the plaintiffs ran out of money to keep the case going. The ABC won its case by default. What was interesting here was the shift in the media’ focus from the administrative and legislative system being at fault to inadequacies with the judicial system. This program set the stage for the need for further legislative change and the enhancement of the powers of the Health Insurance Commission.

On another front, the Bates Report of 1992 was part of a push for administrative reforms. This was an internal report commissioned by the Health Insurance Commission to recommend a review of operations and procedures for the conduct of investigations into fraud and overservicing. It was set up in part to enquire into the leakage of confidential information to private inquiry agents, brought to light by an ICAC investigation (ICAC: Report on the Unauthorized Release of Government Information, vol 1 & 3, 1992). It also argued that "the level and seriousness of medifraud is likely to have increased since the investigation function was transferred to the Health Insurance Commission. In part, this could be attributed to the reduction in effort and lack of expertise currently allocated to this task". (Bates 1992: 4) And again, "Offences of fraud and associated offences contained in both the National Health Act and the Health Insurance Act are complex, inconsistent and in some cases (eg. pathology) unenforceable…It is incongruous that the Health Insurance Act acknowledges the possibility of serious frauds being committed in the area of medical benefits but is totally silent on the issue of powers which would support investigative activity" (Bates: p14).

What were needed, it was argued, were improved powers of investigation so the department could conduct their own investigations and so by-pass the Federal Police, the agency who carried out the investigations. The problem was the Australian Federal Police did not give a priority to this type of crime. The media, had a role in publicising this much need enhancement of the powers of the Health Insurance Commission. Yet these powers would offer no guarantee that the judicial system would support the commission no matter how strong its case.

The Senate passed the legislation with some amendments (Health Legislation (Powers of Investigation) Amendment Act 1994 and the Health Legislation (Professional Services Review) Amendment Act 1994. But some time later, it was disclosed that the original legislative team had been removed 8 months into the writing process. The AMA while originally supportive of the need for legislative reform, changed its mind on the subject and argued to the Minister for Health, then Graham Richardson and the Department of Health that privacy considerations could not be guaranteed with the new legislation. So a compromise was reached. The work of writing the legislation would proceed but the people writing it would be dismissed. In its place would be a team drawn from the AMA, the Department of Health and the Ministry!

In 1998 ABC television journalist, Ray Moynihan, was writing a book on overservicing Too Much Medicine and tipped fellow journalist David Hardacre working on the 7.30 Report about a case which had come before the Professional Services Review Committee. This committee had tries to get a doctor convicted for inappropriate conduct for massive overservicing. The case against the doctor failed even on appeal. Again, like the Bacich case of 1990 the case had gone to a judicial system which found against the government.

However, it is Moynihan’s (1998:120) account of overservicing that identifies a new problem; that the overuse of antibiotics is counterproductive as a health care strategy. The practice of over prescribing is directly related to overservicing as short consultation times mean that prescriptions for antibiotics are issued without reference to real medical need. The issue is now not only one of financial corruption but that the practice of medicine has also become corrupted.

In order to understand how difficult fraud control policy has been in this area there is a need some history of health policy in Australia. The fee-for service system, rather than capitation or salary for the payment to doctors has been identified as a major contributor to cost escalation under Medicare (Sax 1984: 138; Deeble 1991: 74; Scotton & Macdonald 1993: 205; Palmer & Short 2000: 328). Others (Richardson 1987; Sparrow 1996) question this assessment and indicate that fraud control is difficult under any insurance payment system. Many doctors, on the other hand, would argue that third party intervention between doctor and patient for the payment of fees, as occurs under health insurance, is the essence of the problem. This is not to question the legitimacy of national health insurance, any particular payment system or medical professional autonomy. However, when these are combined with minimal controls on fees and volume of services and a poor regulatory framework, then the opportunities are presented to some doctors to maximize the provision of services and to perpetuate fraud. The subsequent drain on the public purse is far larger than governments are prepared to acknowledge.

It is easy to imagine that somehow fraud and overservicing policies were forgotten in the rush to get Medibank up and running. But this was not entirely the case. The architects of Medibank, Richard Scotton and John Deeble, together with the five Labor MPs, who were physicians, favoured the British model of a National Health Service, where the capitation of salaries, meant that doctors while well paid and received remuneration in accordance with patients numbers. However, Deeble and Scotton were not in a position to consider this alternative, as they were constrained by the Commonwealth Constitution. A politically astute Australian Medical Association had long before moved to protect their professional autonomy and guard against, what they perceived to be, the threat of nationalization. Into the constitutional referendum in 1946, Robert Menzies, then leader of the opposition, on the suggestion of Henry Newland, later president of the AMA, inserted a clause prohibiting civil conscription (Hunter 1980: 197). From this time on, fee-for-service became an entrenched feature of the health system (Gillespie 1991: 24-9; Scotton 1994: 7).

So Medibank was formulated within the limitations imposed by the Constitution, the constraints of a shortage of time for policy development, and by the desire of the Whitlam government to introduce a health policy that would be electorally popular. This meant that the Commonwealth funded compulsory health insurance. There was also an understanding that confining pathology services to the hospital system, as in Canada would not be possible, as large private pathology practices were already in existence in Australia. This was to be problematic almost from the onset of the introduction of Medibank, as unscrupulous companies within the pathology industry exploited opportunities for fraud and overservicing. The first official investigation into this issue was started as early as 1977 with the publication of the report of the Pathology Practices Working Party.

Fraud control policies reflect the complexities of the systems governing the implementation of public programs (Gardiner & Lyman 1984: 11). Additional structural hindrances to effective fraud control policies come from the division of responsibilities for health between the Federal government and the States. The States have control over the registration of individual doctors and control over professional behaviour. But state legislation does not cover fraud and overservicing, nor do the states have any incentives to introduce additional legislation because responsibility for this function rests with the federal government (Palmer & Short 2000: 208-9).

At the centre of the issue of control of fraud and overservicing is the question of definition. Medical fraud is taken to mean "the receipt of a payment by a doctor when no service has been provided, or when the claim for payment refers to a more costly item than the service actually provided. Overservicing, on the other hand, refers to the provision of services that are not reasonably necessary for the adequate care of the patient concerned" (Palmer & Short 2000: 196). On first appearances it would seem that fraud would present no problems of definition, however, when the deception or misrepresentation relates to the question of medical necessity the distinctions between fraud and abuse (or between fraud and defensive medicine, or between fraud and well-intentioned over zealousness) become quite blurred (Sparrow 1996: 50). If the physician in question is aware that the services were not reasonably necessary then it is apparent that any medical benefit will have been obtained fraudulently (Cashman 1982: 117).

These definitional ambiguities make it difficult to measure fraud systematically, and without proof, the medical profession refuses to contemplate more stringent controls" (Sparrow 1996: 62). The medical profession is then reluctant to unequivocally condemn fraudulent practice and without the support of the professional bodies the debate focuses on the size of the problem, rather than on solutions (Wilson & Grabosky 1986: 161; Sparrow 1996: 62). And as one commentator noted, "we have no idea of the scale of fraud and, indeed, it is part of the fraud that we cannot easily find out" (Opit 1981: 44).

Has the situation improved over the years? This is hard to judge, for without random audits there is no way of finding out the extent of fraud. The last audit in 1997 showed fraud and inappropriate practice coming in at around 1.3% to 2.3%. (ANAO 1997) If this were the real figure for leakage against Medicare then fraud experts from around the world would be coming to Australia to work how we got it right. Well they’re not flocking here. The estimate (guesstimate) in the United States is 20% to 35% (Glasheen I. 1997 [http://www.aarp.org/bulletin/oct97/sparrow1.html])

Giving his opinion of the situation in the United States and in Australia, Warwick Graco of the Professional Review Division of the Health Insurance Commission said:

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Interviews:

Warwick Graco….14/8/01

Michael Smith……31/1/00