The price of pain: Questionable billing by doctors rife in Australia

Trudi King is always in pain.

“The only relief you get is when you go to sleep,” the 60-year-old says.

In 2021, she had spinal fusion surgery at a private hospital in Sydney after struggling with back pain for four years.

“All I wanted was to live a pain-free life,” she says.

When she woke up, she couldn’t feel her feet. 

A woman sits in a wheelchair, inside a home. She is looking at the camera with a serious expression.
Trudi King. (Four Corners: Chris Gillett)

“I was terrified … no one really told me what was going on,” she says.

Trudi had a second surgery the next day. There were serious complications and she was in a coma for almost three weeks.

When she finally got home, she had to use a wheelchair.

As for the pain, it’s now even worse.

Trudi is one of more than three million Australians grappling with the relentless agony of chronic pain. Back pain is the leading cause of disability and lost productivity in Australia and globally.

It has spawned a multi-billion-dollar industry offering treatments including spinal surgeries and medical devices – the majority done in the private sector.

For the past six months, Four Corners has been investigating the trail of misery it has left behind. For some it’s meant more pain, paralysis, and even death.

A woman sits on a couch inside a home. Next to her is her motorised wheelchair.
Trudi still requires the use of a wheelchair. (Four Corners: Chris Gillett)

Spinal fusion costs tens of thousands of dollars. Trudi’s experience cost her health fund a fortune.

What she now knows, after the investigation by Four Corners, is that not only did her surgery cause her harm, but some of her medical bills raise concern.

An analysis of Trudi’s records by medical billing expert Margaret Faux found questionable billing from anaesthetists involved in her surgery.

Dr Faux, the founder of medical technology company Synapse, did not have access to Trudi’s full medical records, but analysed her private health insurance and Medicare bills for the time she was in hospital, including the period she was in a coma.

“There are red flags because during that same period, a number of doctors came into the intensive care unit,” she says.

“The services that they billed are services that require the doctor to have a discussion with the patient; not their relatives, not their colleagues – with the patient – because you have to explain treatment to the patient.

“I do not understand how it is possible to have a discussion with an unconscious patient who is in a coma.”

It’s not an isolated case.

Four Corners has obtained the private health insurance billing records of more than 23,000 patients who underwent spinal surgery in Australia between November 2017 and May 2023.

Across the full data set, the analysis found:

  • 77 per cent were billed for more complex services than provided
  • 10 per cent were billed for longer services than provided; and
  • 7 per cent were billed for spinal fusions for chronic lower back pain without a diagnosis, in breach of a Medicare rule

The de-identified data was supplied by six private health funds, representing 25 per cent of the private health fund industry.

The records were sent for analysis to Dr Faux and a team at Synapse, as well as a team at Kirontech, a UK-based health fraud investigation company that used its specialist detection software.

They cross-checked the analysis and wrote a report. Together, they found more than 20 per cent of the bills they assessed raised questions.

A woman stands at a high-rise office window, her back to the camera. The window is covered with x-rays.
Margaret Faux has analysed Trudi’s records. (Four Corners: Chris Gillett)

The experts state in their report there is a strong suggestion of “a serious fraud, waste and abuse problem requiring urgent attention”.

The terms “fraud, waste and abuse” are used widely in the industry and can cover conduct ranging from errors, to overservicing, to fraud.

Rachel David, CEO of Private Healthcare Australia, says if the findings were applied to the whole industry for spinal surgery, it would signal a huge draining of the health system by some medical professionals.

“We’re talking about half a billion dollars.”

The team analysing the data ran complex algorithms to exclude the possibility of other medical explanations, but without each patients’ medical records it’s impossible to be conclusive.

Most of the questionable billing came from anaesthetists and surgeons.

Here’s how it works …

Every time a patient is admitted to hospital in Australia, that admission generates a number of bills across the health system.

Among them are bills from individual medical practitioners, claiming payment from a patient’s private health fund and Medicare for the services they say they provided.

Practitioners charge for their services using codes. Each code represents a specific service.

As it’s based on an honour system, they are automatically paid without checks that the services took place.

Red flags can emerge when the codes used by different practitioners involved in the same surgery are compared.

For example, each of these surgeries involved a fluoroscopy, an imaging procedure often used in spinal fusions.

The billing code used indicates the surgeries took less than one hour.

But the time billed by the anaesthetists in those same surgeries is much longer.

The analysis applied a buffer to take into account anaesthetic times are always longer than surgical times.

This means the anaesthetists charged the health system more …

… including one who billed for more than 14 hours of work at an added cost of over $2500.

The analysis also uncovered questionable billing patterns among surgeons … including charging for advanced procedures in implausibly short times.

In these surgeries, the anaesthetist billed for 2.5 hours or less … but the surgeon charged for procedures that even the quickest practitioner would be unlikely to complete in the available time.

For each additional level of spinal fusion surgery, surgeons claim an extra $1350 on average.

In this surgery, a patient allegedly underwent three complex procedures in 20-35 minutes.

An expert who analysed the data said it was highly unlikely even a fast surgeon would be able to complete all three in that time.

Kirontech’s chief medical officer Dr Simon Peck – who is also a former anaesthetist – says the findings are alarming.

“We’ve looked at data from all around the world, and I would say the indicators of misbilling … is at the top end of the scale,” Dr Peck says.

“Medical bills are paid on the basis of trust … After a while, when people realise that they’re not being checked up on, they start … to push the boundaries.”

A woman stands looking at a group of x-rays on a window.
Dr Faux is a medical billing expert. (Four Corners)

The system is hitting the patient twice, Dr Faux says.

“We are exploiting them clinically by offering them treatments and procedures that … can be harmful, and then a second time financially.”

Last year, an Independent Review of Medicare Integrity and Compliance, commissioned by Health Minister Mark Butler, found “legislation, governance, systems, processes and tools are currently not fit for purpose and, without significant attention, will result in significant levels of fraud”.

The review made several recommendations to be implemented to strengthen the Medicare system.

Trudi says she’s now in worse pain than before her surgery.

“It’s just a dark place you have to mentally deal with,” the grandmother of three says.

“I was very active, and I liked fishing and walking. [Now] I’ve got three grand babies under five and I can’t play with them like I want to.

“It’s like, ‘Nanny’s always sick.'”

The need for surgery

Trudi regrets deciding to have the surgery.

Spinal fusion involves permanently joining two or more vertebrae to prevent movement between them.

Trudi had three bones fused. She says an X-ray had found disk degeneration.

Spinal fusion is an accepted surgery for treating people with congenital spinal disorders, those who have broken their back, and some other conditions.

Sometimes it is recommended as a treatment for chronic back pain but a rising number of health researchers and surgeons say it’s not an effective treatment.

A man stands at a high-rise office window looking at dozens of x-rays on the window.
Ian Harris questions the use of spinal fusion for people with chronic pain. (Four Corners: Chris Gillett)

Orthopaedic surgeon Ian Harris says there have only been a handful of trials.

“Those trials, when put together, don’t show a clear benefit of surgery,” he says.

“Some surgeons are very unlikely to recommend the procedure … it tells us that someone’s wrong.”

Professor Harris says MRI scans pick up abnormalities in most people aged over 40.

“The more things you find, the more likely it is that you’ll end up with somebody wanting to treat or correct that abnormality – even though correcting that abnormality might not help the patient because it might not be associated with their pain.”

A man stands looking at a number of X-rays in front of him.
Ian Harris is an orthopaedic surgeon. (Four Corners)

More than 70 per cent of spinal fusions are done in the private sector, the latest figures estimate. The more bones that are fused, the higher the cost of the surgery.

Professor Harris is concerned this financial incentive drives more surgeries.

“The more you get paid for a procedure, the more likely it is that that procedure will be done,” he says.

“It’s too easy for us to let these other incentives influence our decision making.”

Trudi says she’s now trapped in the pain industry.

“I’m never not in pain,” she says.

“Now I’m on this cycle; pain doctors … neurologists …”

She says she’d like to ask the surgeon who operated on her, “What the hell did you do?”

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