Government eyes health insurers' data to help uncover Medicare fraud

The Department of Health has launched a public consultation on proposed legislation that would lay the basis for increased data-matching between government entities in order to uncover fraudulent or incorrect Medicare claims. The proposal could also see the data provided from private health insurers automatically matched against government data holdings to red flag potential fraud.

A consultation guide released by the department states the proposed Health Legislation Amendment (Data-Matching) Bill 2019 and associated regulations won’t give the department new powers to conduct compliance activities and will not “authorise the automation of compliance outcomes or raising of debts” (although such activity could be conducted with human oversight on the basis of anomalies flagged by data matching).

If passed, the bill would enable Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) data to be automatically cross-matched against data from the Department of Veterans’ Affairs, the Therapeutic Goods Administration, data from private health insurers and registration information from the Australian Health Practitioner Regulation Agency, as well as immigration data provided by the Department of Home Affairs.

Data from private health insurers would be provided to the department by the insurers on a voluntary basis; no Medicare data would be provided to private health insurers, however. Data from the My Health Record system would not be in the scope of the data-matching proposals.

The data-matching scheme would have three key aims: Detecting Medicare fraud, detecting incorrect claiming and detecting inappropriate practices by health providers.

The Department of Human Services earlier this year released details of a data-matching scheme combining data from Centrelink and Medicare to unearth discrepancies between records held at the two agencies in order to tackle fraud or overpayments.

A controversial government data-matching scheme dubbed ‘robodebt’ by its critics, which combines data from Centrelink and the Australian Taxation Office to flag potential overpayment of welfare benefits, is currently the subject of a prospective class action lawsuit.

The health department’s consultation guide states that, currently, MBS and PBS data can be matched in “narrow circumstances”.

“The proposed legislation will exclude data matching from this restriction when the matching is undertaken for specified Medicare compliance purposes,” the document states.

The department commissioned a Privacy Impact Assessment of the proposed data-matching legislation from KWM and Galexia.

The PIA was limited to the use of the matched data by the health department, with the authors noting that meant it only assessed the proposals in the context of provider compliance (so it didn’t, for example, examine the use of matched data by the Department of Human Services). An executive summary of the PIA and the department’s response to its recommendations have been released.

The department agreed or agreed in principle with 12 recommendations made in the document, including greater openness about its data-matching activities and ensuring corrections to data are shared with third parties involved in matching processes.

The guide states the legislation will require Medicare’s chief executive “systems and processes” to ensure that information matched “is reasonably necessary” for identified purposes, ensure the information used for matching is accurate, up-to-date and complete; ensure the timely destruction of information that is not in use; and maintain a public register of matching activity.

The draft bill requires the Medicare chief consults with the Australian Information Commissioner on the relevant “systems and processes”.

The draft legislation and regulations, consultation guide and PIA documents are available from the department’s website. Submissions close 11 October.

Copyright © 2019 IDG Communications, Inc.

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