Our client, a state government regulator overseeing workers compensation schemes, engaged us to assess the integrity of medical practitioner billing and claims management processes.
Following initial discussions, we agreed to a proof-of-concept project. Synapse was tasked with analysing medical specialist invoices (excluding GPs) for 1,000 workers compensation claims identified by the regulator as having high utilisation of medical services.
We reviewed over 32,000 invoice lines totalling nearly $30 million, uncovering approximately $10 million in incorrect payments.
Key issues included:
- Lack of transparency – Anaesthetic billing breakdowns are hidden due to AMA rules, allowing excessive use of modifiers and inflated time units.
- Weak internal controls – Payers frequently paid incorrect rates and invalid item combinations.
- Low billing literacy – Among both claims processors and medical practitioners, leading to systemic errors.
- Absence of clear billing rules – No consistent application of any formal billing framework.
- Widespread confusion – Between AMA, MBS, Workers Compensation Fee Orders, and the ASA RVG Guide for anaesthetists.
- Evidence of upcoding – Suggesting deliberate inflation of service claims.
Our findings highlighted the urgent need for improved billing literacy, clearer rules, and stronger controls to protect scheme integrity and reduce waste.