{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T05:29:31Z","timestamp":1791869371081,"version":"4.3.4"},"reference-count":21,"publisher":"Public Library of Science (PLoS)","issue":"1","license":[{"start":{"date-parts":[[2022,1,21]],"date-time":"2022-01-21T00:00:00Z","timestamp":1642723200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"\n Background<\/jats:title>\n Medical billing errors and fraud have been described as one of the last \u201cgreat unreduced healthcare costs,\u201d with some commentators suggesting measurable average losses from this phenomenon are 7% of total health expenditure. In Australia, it has been estimated that leakage from Medicare caused by non-compliant medical billing may be 10\u201315% of the scheme\u2019s total cost. Despite a growing body of international research, mostly from the U.S, suggesting that rather than deliberately abusing the health financing systems they operate within, medical practitioners may be struggling to understand complex and highly interpretive medical billing rules, there is a lack of research in this area in Australia. The aim of this study was to address this research gap by examining the experiences of medical practitioners through the first qualitative study undertaken in Australia, which may have relevance in multiple jurisdictions.<\/jats:p>\n <\/jats:sec>\n \n Method<\/jats:title>\n This study interviewed 27 specialist and general medical practitioners who claim Medicare reimbursements in their daily practice. Interviews were recorded, transcribed, and analysed using thematic analysis.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The qualitative data revealed five themes including inadequate induction, poor legal literacy, absence of reliable advice and support, fear and deference, and unmet opportunities for improvement.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n The qualitative data presented in this study suggest Australian medical practitioners are ill-equipped to manage their Medicare compliance obligations, have low levels of legal literacy and desire education, clarity and certainty around complex billing standards and rules. Non-compliant medical billing under Australia\u2019s Medicare scheme is a nuanced phenomenon that may be far more complex than previously thought and learnings from this study may offer important insights for other countries seeking solutions to the phenomenon of health system leakage. Strategies to address the barriers and deficiencies identified by participants in this study will require a multi-pronged approach. The data suggest that the current punitive system of ensuring compliance by Australian medical practitioners is not fit for purpose.<\/jats:p>\n <\/jats:sec>","DOI":"10.1371\/journal.pone.0262211","type":"journal-article","created":{"date-parts":[[2022,1,21]],"date-time":"2022-01-21T13:35:15Z","timestamp":1642772115000},"page":"e0262211","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9782-6842","authenticated-orcid":true,"given":"Margaret","family":"Faux","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jon","family":"Adams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simran","family":"Dahiya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jon","family":"Wardle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,1,21]]},"reference":[{"key":"pone.0262211.ref001","volume-title":"The Financial Cost of Healthcare Fraud 2014: What Data from Around the World Shows","author":"Jim Gee","year":"2014"},{"key":"pone.0262211.ref002","first-page":"27 JLM 66","author":"Margaret Faux","year":"2019","journal-title":"Medicare Billing, Law and Practice: Complex, Incomprehensible and Beginning to Unravel"},{"issue":"1","key":"pone.0262211.ref003","article-title":"What is wrong with Medicare?","volume":"196","author":"T Webber","year":"2012","journal-title":"MJA"},{"key":"pone.0262211.ref004","author":"M Faux","year":"2018","journal-title":"Who teaches medical billing? A national cross-sectional survey of Australian medical education stakeholders: BMJ Open"},{"key":"pone.0262211.ref005","unstructured":"https:\/\/www1.health.gov.au\/internet\/main\/publishing.nsf\/Content\/health-compliance#Changes (accessed 8 March 2020)."},{"issue":"11","key":"pone.0262211.ref006","article-title":"Burnout in the medical profession: not a rite of passage","volume":"208","author":"Michael Baigent","year":"2018","journal-title":"Med J Aust"},{"issue":"6","key":"pone.0262211.ref007","first-page":"678","article-title":"A National Survey of Medical Coding and Billing Training in United States Dermatology Residency Programs","volume":"17","author":"KB Paz","year":"2018","journal-title":"Journal of Drugs in Dermatology: JDD"},{"key":"pone.0262211.ref008","unstructured":"The MBS are unique billing codes used only in Australia. The MBS codes have no connection with the International Classification of Disease, Current Procedural Terminology, SNOMED-CT, LOINC or any other codes set or classification system."},{"key":"pone.0262211.ref009","volume-title":"Qualitative Research Methods","author":"D. E P Liamputtong.","year":"2005"},{"key":"pone.0262211.ref010","volume-title":"Qualitative Research in Health Care","author":"P. A Mays","year":"2006"},{"key":"pone.0262211.ref011","unstructured":"Items 23 and 36 are commonly billed time-based GP attendance items. Item 23 is an attendance of less than 20 minutes and item 36 is from 20 to 40 minutes. Both have other requirements relating to complexity. They can be viewed at www.mbsonline.gov.au."},{"key":"pone.0262211.ref012","unstructured":"The formal legal process for bulk billing is described in Section 20A of the Health Insurance Act 1975 (Cwth), wherein an eligible person (a patient) assigns his\/her right to a Medicare rebate to a medical practitioner and the medical practitioner is prohibited from charging a gap. It can be viewed at www.legislation.gov.au."},{"key":"pone.0262211.ref013","unstructured":"National Health Funding Body, Public Hospital Funding, National Health Reform Agreement https:\/\/www.publichospitalfunding.gov.au\/public-hospital-funding\/about-agreement (accessed 8 March 2020)."},{"key":"pone.0262211.ref014","doi-asserted-by":"crossref","first-page":"939","DOI":"10.1177\/0009922809337622","article-title":"Inadequate training in billing and coding as perceived by recent pediatric graduates","volume":"48","author":"D. K. Andreae MC","year":"2009","journal-title":"Clin Pediatr (Phila)."},{"issue":"20","key":"pone.0262211.ref015","doi-asserted-by":"crossref","first-page":"1856","DOI":"10.1212\/WNL.0000000000000983","article-title":"Education in medical billing benefits both neurology trainees and academic departments,","volume":"83","author":"Jeff L. Waugh","year":"2014","journal-title":"Neurology"},{"issue":"5","key":"pone.0262211.ref016","article-title":"How accurate are we? A comparison of resident and staff physician billing knowledge and exposure to billing education during residency training","volume":"62","author":"E Ryan","year":"2019","journal-title":"J Can Chir,"},{"issue":"2","key":"pone.0262211.ref017","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1111\/imj.12665","article-title":"No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?","volume":"45","author":"MS Faux","year":"2015","journal-title":"Intern Med J"},{"key":"pone.0262211.ref018","unstructured":"Victorian Auditor General\u2019s Office, Managing Private Medical Practice in Public Hospitals, Independent assurance report to parliament 2018\u201319:30 ISBN 9781925678550."},{"key":"pone.0262211.ref019","unstructured":"Troubling Ambiguity: Governance in SA Health, A Report by the Honourable Bruce Lander QC, Independent Commissioner Against Corruption, published 29 November 2019."},{"key":"pone.0262211.ref020","first-page":"2018","article-title":"The Broken Medicare Appeals System, Failed Regulatory Solutions and the Promise of Federal Litigation","volume":"281","author":"Greer Donley","journal-title":"Health Matrix"},{"key":"pone.0262211.ref021","unstructured":"Justice Alan Robertson, Natural Justice or Procedural Fairness, Judges and the Academy Speech 4 September 2015. Federal Court of Australia. Can be read at this link https:\/\/www.fedcourt.gov.au\/digital-law-library\/judges-speeches\/justice-robertson\/robertson-j-20150904."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0262211","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,1,21]],"date-time":"2022-01-21T13:35:48Z","timestamp":1642772148000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0262211"}},"subtitle":[],"editor":[{"given":"Kathleen","family":"Finlayson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2022,1,21]]},"references-count":21,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,1,21]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0262211","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2020.05.26.20113324","asserted-by":"object"}]},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,1,21]]}}}