When Lisa Crotty discovered a hospital had billed her chronic pain treatments as cerebral palsy/muscular dystrophy procedures, conditions she doesn't have, she was stunned.
What concerned her more was the attitude of the private hospital's billing department when she alerted it to the extra money it had pocketed from the billing errors.
"They said to me, 'why are you concerned? It's not coming out of your pocket, your health fund is paying'," she said.
Her private health records show the incorrect billing occurred twice, once in October 2023 and again in February this year, which resulted in the overcharging of her private health fund more than $2,000 following a procedure known as nerve ablations, where a portion of the nerve is destroyed or removed to reduce pain.
"I couldn't believe what I heard," she said.
"I was told they would look into it, but I have not heard back."
Lisa is one of several chronic pain sufferers whose medical bills that reveal anaesthetists apparently billing for fictitious services and hospitals, anaesthetists and physicians submitting inflated bills.
It follows a Four Corners investigation into the chronic pain industry, which exposed over treatment and questionable billing practices in the multi-billion-dollar sector.
The revelations prompted Federal Health Minister Mark Butler to ask his department to "urgently" investigate the matters further. There are also now urgent calls for reforms.
'He was just lining his own pockets'
Anaesthetist Joanna Sutherland, who chairs the Safety and Quality Committee of the Australian and New Zealand College of Anaesthetists (ANZCA), described the anaesthesia billing system as unfit for purpose and said it was open to misinterpretation and misapplication.
"In my opinion it is in the interests of providers, patients and funders that it be substantially reformed," Dr Sutherland said.
The Four Corners program led to a flood of patients sending questionable billings to ABC investigations.
One patient, who asked not to be named, said he was shocked when his anaesthetist sent him a notice to pay for a service that didn't happen because the surgery was cancelled by the hospital days earlier.
It requested he pay the outstanding amount as his private health fund and Medicare had not paid the bill in full.
He said he called, visited, and wrote to the anaesthetic service in an attempt to understand how a private health fund and Medicare had been billed (and paid) for a service that didn't happen.
"How did the fund even pay for this? How many others have they paid that they shouldn't have? How could it have been paid. How?" he wrote in an email to the clinic last June.
His local politician weighed in and wrote to the clinic, asking for an explanation. The clinic told the politician it had apologised to the patient for the "mess" and said it was still to refund Medicare and the private health fund.
"We will do our very best to resolve the problems with this account as we want the best for our providers and also our patients."
Another patient provided medical and billing records to the ABC that showed his anaesthetist billed for services that were not provided, wrongly billed for more complex services and exaggerated the anaesthetic time, all of which paid more money.
Even before the surgery, the patient's wife — herself, a former practice manager — became worried about the way the anaesthetist was charging.
When she called the anaesthetist's secretary to express her concerns, the response was: "this is how he always does it" but then agreed to refund a $500 fee the patient had paid.
Later, the patient noticed that two pre-anaesthetic consultations had been billed and the patient's wife confirmed that neither had lasted longer than 15 minutes, which is a Medicare requirement for the items billed.
"Most people certainly wouldn't have an understanding of these funding arrangements," the former practice manager said.
"This anaesthetist tried to make out like he was doing us a favour … but he was just lining his own pockets when in fact it was an act of fraud against Medicare and our health fund.
"And it's the arrogance too. They think they're untouchable."
In a statement, the Australian and New Zealand College of Anaesthetists (ANZCA) said the overwhelming majority of anaesthetists and specialist pain medicine physicians operate with integrity and make every effort to comply with increasingly complex billing requirements.
It said as the body representing the professional standards of specialist anaesthetists and specialist pain medicine physicians, it supports an investigation of any allegations of overservicing, wastage, and unprofessional behaviour by the relevant federal regulatory authorities.
Red flags in billing data
The Four Corners investigation into the pain industry included a report prepared by international healthcare fraud, waste, and abuse organisation, Kirontech and local medical billing organisation Synapse, which assessed the billing records of more than 23,000 de-identified private health insurance patients who underwent spinal surgery in Australia between November 2017 and May 2023.
The report didn't look at the full medical records, only the private health bills, but it found many red flags in the data, suggesting there was a problem with misbilling including billing for services not provided, billing for longer services than provided, and billing for more complex services than those provided.
The ABC asked Dr Sutherland and medical billing expert Margaret Faux, a registered nurse and lawyer with a PhD in Medicare, who runs Synapse, to review the medical records, Medicare and private health fund records of three chronic pain patients.
These patients were Trudi King, Teresa Burbery, and Jason Parker, who were all featured in the Four Corners investigation in early April.
They described their findings of the three's billings as "troubling" and consistent with the trends found in the Kirontech/Synapse report.
They said in each of the three patients, every anaesthesia bill they reviewed raised concerns.
"One hundred per cent of the anaesthetic claims we reviewed were questionable," they said.
In the case of Ms Burbery, who was left paralysed after her pain specialist struck her spinal cord during a procedure for a trial spinal cord stimulator, her medical records suggest the anaesthetist billed and was paid a higher rebate on her private health fund bill by saying she had "severe systemic disease" that limits her daily life, which didn't match her medical records.
This was confirmed by Ms Burbery and the anaesthetist's own documentation in the medical records.
"This was a classic example of what the medical records say and what was billed being two completely different things," Dr Faux said.
"Neither Medicare nor the private fund were in the room when the service took place, so they have no way of knowing the truth. The system is trust-based and therefore very vulnerable to abuse."
Dr Sutherland said the anaesthesia bills she reviewed with Dr Faux demonstrate what is happening in the current overly complex system.
"What you want is a system which basically needs no external policing. Inconsistencies or mistakes in billing should be immediately apparent to the provider or the payer through a forcing function or something where the computer says no, so it self regulates," Dr Sutherland said.
An appalled Ms Burbery said the findings were "absolutely shocking".
"I really hope it's investigated as a whole," she said.
'I was a cash cow'
Jason Parker's health records raised similar concerns, including apparently fictitious billing and exaggerating of complexity by anaesthetists on at least three occasions between 2019 and 2023, when he had 10 spinal cord stimulator related procedures after a work accident years earlier damaged his back.
Dr Sutherland and Dr Faux noted a series of pre-anaesthesia consultations claimed in 2022 and 2023, where there was no evidence in the medical records that a consultation occurred. They spoke to Mr Parker, who confirmed there was no consultation on each of three occasions, no history taking or examination by the anaesthetist.
They also noted the anaesthetist charged a billing item which said that Mr Parker had "severe systemic or significant disease", which was not supported in his medical records, but paid more.
Mr Parker confirmed his health status at the time of the procedure was not limited by any severe systemic or significant disease.
"Not only was I left traumatised as a result of these brutal surgeries, I was left realising that I was a cash cow for the financial benefit of the practice," Mr Parker said.
"It's a travesty that this continues and the pain industry profits greatly from this process. It has to be seen, investigated and to end."
No evidence of psychosocial history
An audit of Trudi King's experience in an intensive care unit in 2021 uncovered what appears to be even more dubious billing by several anaesthetists and other doctors at a private hospital in NSW.
Much of the questionable billing took place when Ms King was sedated and ventilated and in a coma after spinal fusion surgery went horribly wrong.
Dr Sutherland and Dr Faux said on one occasion a pre-anaesthesia assessment did not meet Medicare requirements.
"There was no evidence of a documented management plan, nor was it consistent with a consultation lasting 15-30 minutes," they said.
They noted other anaesthetic bills that didn't match the medical records included a 45-minute consultation and management plan, while Ms King was in a coma.
"The assessment documentation in the medical records consisted of five words: Complex, IPPV, Sedated and two illegible words," they said.
They also found that one anaesthetist, in addition to billing for a pre-anaesthetic consultation that did not meet Medicare requirements, also billed an advanced surgery service, but the surgery performed did not meet the definition of "advanced" in their view.
They noted that a neurologist and a geriatrician each separately billed Ms King's health fund for a 45 minute consultation and management plan, which required a psychosocial history and medication review.
"We can find no evidence in the medical records of any psychosocial history, no evidence of comprehensive multi or detailed single organ system assessment, no formulation of differential diagnoses, no evidence of comprehensive management plan of significant complexity," they said.
The findings shocked Ms King.
"I feel violated … I trusted them," the grandmother of two said.
"I trusted the private health sector and doctors but it's just about money and that makes me violently ill. It makes me feel sick they would do that. How has it gone on so long that no one has questioned this before?"
Misbilling concerns raised seven years ago
Dr Sutherland said most concerning was the questionable billing they found in the three patients' records were some of the same problems outlined in a 2017 report released by the Medicare Benefits Schedule (MBS) Review Taskforce Anaesthesia Clinical Committee, which she chaired.
"Here we are seven years later, and the problems appear to have worsened at significant cost to taxpayers," Dr Sutherland said.
The taskforce, completed during the Turnbull government, reviewed more than 500 Medicare items related to anaesthesia, which accounted for more than $528 million in benefits.
Of the more than 60 recommendations that were made, many were not accepted or significantly watered down after sector feedback.
Dr Sutherland and Dr Faux urged the federal government to revisit some of the 2017 MBS taskforce recommendations, including a reform of the anaesthesia billing system.
They also called on the government to give the Medicare regulator, the Professional Services Review (PSR), additional powers to have the discretion to launch its own investigations, starting in the area of chronic pain and spinal interventions, including anaesthesia and other related services.
ANZCA said it supports the work of the PSR in investigating inappropriate practices in Medicare billing.
"Any changes to the referral process would require widespread consultation and legislative change," it said.
Private Healthcare Australia chief executive Rachel David said she was concerned by the misbilling and asked the government to urgently amend the law to enable the sharing of data between funds and Medicare in a bid to reduce wasteful or fraudulent billing.
Under the current laws, health funds and Medicare can't share data and can therefore only see part of the billing picture, which makes it harder to detect misbilling, which is draining our health system.
The Four Corners exposé into the multi-billion dollar chronic pain industry found the sector had become a breeding ground for exploitation.
Kirontech chief medical officer and trained anaesthetist Simon Peck has been working in this arena for more than 20 years and said fraud, waste and abuse was a problem in every healthcare system he has looked at without exception.
"The patterns are remarkably predictable," he said.
"So much so I used to say to the sceptics 'If you say there is no problem it means you haven't actually looked. And the more times that you deny that you have a problem the bigger it will be when you eventually do look.'"
He said he is yet to be wrong.
