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Pressure points - Medicare compliance

17 June 2019 | Dr Penny Browne, MBBS, FRACGP, MHL, Chief Medical Officer, Avant

Medicare compliance is currently a high priority for the Department of Health, as demands on the healthcare system continue to rise.

Given the increasing complexity – the Department’s increased focus and significant changes to the Medicare Benefits Schedule (MBS) – it’s essential to understand the compliance program. It's also important to regularly review your practice and familiarise yourself with revisions to MBS items you bill.

A time of change

In the past year, the compliance program has been expanded. Improved data analytics and increased staffing are driving more reviews of not just general practitioners' billing practices but also specialists’. In addition, the Professional Services Review’s (PSR) activity has increased, with recoveries doubling in the past financial year.

The MBS Review is another initiative affecting billing practices, with over 5,700 items being reviewed. Many new and revised items will be rolling out this year.

Further, from 1 July 2019, the Department of Health will have powers to recover debts from not just health professionals but corporate bodies under the new Shared Debt Recovery Scheme.

All these changes are why we're receiving more Medicare-related queries to our Medico-legal Advisory Service (MLAS) and claims concerning billing.

A new way of reviewing

While the vast majority of health professionals comply with requirements, the Department has continued to improve compliance strategies to focus on prevention and early intervention. It is taking a new behavioural economics-driven approach to encourage health professionals to improve their practice, primarily through new 'review and act' letters.

These letters are being sent to groups of health professionals who have higher billing or prescribing rates on particular MBS and Pharmaceutical Benefits Scheme items compared to their peers. The letters provide education on appropriate practices and require doctors to review their billings or prescribing. If a doctor has billed incorrectly, they are required to notify Medicare and pay back any incorrect billings.

While these letters don’t indicate that you will be audited by Medicare, the Department will continue to monitor the relevant items of concern in the future and the Department may take compliance action, such as an audit, if concerns are identified. Please contact us at nca@avant.org.au or on 1800 128 268 if you receive one of these letters and require further information or advice.

Being audited by Medicare  

Should you or the corporate body you work for be audited, a ‘notice to produce’ medical records will be sent.

You will need to provide medical records to substantiate the MBS item numbers in question. You can redact any information irrelevant to the item numbers, however, care is required to ensure you don’t censor information that supports your practice.

A patient whose clinical information has been disclosed for a Medicare compliance audit doesn’t need to be informed of the disclosure.

When the records have been reviewed, you will be notified about the audit’s outcome and informed about whether a debt will need to be paid. If you disagree with the outcome, you can request a review within 28 days of the outcome notice.

If during the audit inappropriate practice is identified, Medicare may refer your matter to the PSR for investigation.

We recommend you contact Avant for assistance with the audit process, a request for review or if the PSR contacts you.

Tips to mitigate risks

A lack of notes explaining why a particular treatment or approach was clinically relevant to meet an item descriptor, makes it difficult to justify billings if audited.

To mitigate risk of an adverse outcome, records should:

  • have separate entries for each attendance by the patient for a service and the date the service was provided or initiated
  • include adequate clinical information to explain the type of service provided or initiated at each attendance
  • be sufficiently comprehensible that another doctor could rely on it for ongoing care
  • be written at the time the service was provided or as soon as practicable afterwards.

When determining if an MBS item meets the description, consider if your peers would accept the treatment provided as necessary and appropriate for the patient.

Another area of concern for doctors is when they have given up control of their billing and centralised functions within their organisation contributed to the incorrect billing.

Even if your billing is undertaken by administrative staff at your practice or hospital, you are still responsible for their accuracy and they should be reviewed on a regular basis. This will soon be a joint responsibility when the Shared Debt Recovery Scheme comes into effect from 1 July 2019.

Shared Debt Recovery Scheme

The Shared Debt Recovery Scheme will allow Medicare to apportion debts arising from a false or misleading statement (e.g. claim for benefit) between the providing practitioner and a secondary debtor, such as a hospital, corporation or practice.

Medicare can make a shared debt determination where it is reasonably believed the:

  • secondary debtor could have controlled or influenced the circumstances that led to the making of the false or misleading statement
  • secondary debtor directly or indirectly obtained a financial benefit from the making of the false or misleading statement
  • circumstances of the case make it fair and reasonable for the determination to be made.

It is important that all people involved in billing patients understand their relevant MBS item descriptors and the compliance process, to minimise incorrect billing practices.

Collaborating on change

In a time of increasing complexity and compliance activity, Avant has been working with the Professional Services Review and the Department of Health to ensure the impact of changes on the medical profession is carefully considered.

A submission has also been made on the Shared Debt Recovery Scheme and Avant is actively participating in the consultation process, to ensure clarity on its application and responsibility is fairly apportioned.

We are also collaborating with the Department’s new education branch on the development of educational resources for doctors, to address common knowledge gaps and compliance issues.

Useful resources

Read our article Reforms to Medicare compliance for more information on the changes.

Visit the Department of Health’s website for Administrative record keeping guidelines for health professionals or access this e-learning course on Medicare billing and claiming basics.

This article was originally published in Connect Issue 12.

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