Opinion
Medicare compliance is ramping up: What GPs need to know
The Department of Health is cracking down on Medicare compliance. Medico-legal expert Sara Bird has some recommendations to help GPs.
The Government recently announced it would spend $9.5 million over five years to improve Medicare compliance arrangements and debt recovery.
In the case files that we have opened over the past week, one third of all new investigations were related to Medicare.
That’s unusual. Normally, that figure is only 10%.
It’s a sign that the Department of Health (DoH) is ramping up its scrutiny of Medicare billing.
In May last year, the Government announced it would spend $9.5 million over five years to improve Medicare compliance arrangements and debt recovery. This is now resulting in a greater volume of Medicare audit and review activities for GPs and other specialists.
We can see the results in the Professional Services Review Director’s Updates. In June, a GP agreed to repay $428,000 and was disqualified from providing some Medicare Benefits Schedule (MBS) items for 24 months and other items for 12 months.
Of note, and perhaps of some reassurance to GPs, there has recently been increased scrutiny of specialists other than GPs. For instance, the July Professional Services Review Director’s Update includes a report of repayment of $1,186,093.05 by a consultant physician in respiratory and sleep medicine.
MBS items commonly being reviewed include chronic disease management services (especially team-care arrangements where the requirements to meet the item descriptor are quite specific), mental health plans, after-hours items and skin cancer items. You may also come under scrutiny if your ratios are well outside those of your peers (eg items 23:36 or 23:44).
Types of DoH activities:
- Targeted letter campaigns and voluntary self-audits, such as the ‘Review and Act Now’ letters
- Compliance audits – these are designed to ensure benefits are being paid in accordance with the legislation, and may involve the mandatory production of documents to substantiate Medicare claims
- Practitioner Review Program – after being provided with a list of the DoH’s concerns and the relevant Medicare data, practitioners are then asked for an initial interview with a peer. This interview may result in the DoH’s concerns being addressed with no further action, ongoing review of Medicare data following a period of review, or potentially a referral to the Director of the Professional Services Review
- Professional Services Review – where the Director initially undertakes a review of the GP’s provision of services to consider if there is a possibility of ‘inappropriate practice’ (defined as conduct in connection with rendering or initiating services that a committee of peers could reasonably conclude was unacceptable to the general body of GPs) or breaking the 80/20 rule (rendering 80 or more professional attendance services – not patients – on 20 or more days during a 12-month period)
What can GPs do to avoid problems?
First, know the MBS item descriptors. Ensure you read and understand the MBS descriptors for the items you bill. If uncertain, seek advice from your medical defence organisation or
AskMBS@health.gov.au
Make sure you keep adequate medical records. ‘Inappropriate practice’ may be found where you have provided the service but your medical records are found to be inadequate. The legislative standards for ‘adequate and contemporaneous’ medical records are that:
- the record must include the name of the patient
- the record must contain a separate entry for each attendance by the patient for a service
- each separate entry for a service must
- include the date on which the service was rendered or initiated
- provide sufficient clinical information to explain the service
- be completed at the time, or as soon as practicable after, the service was rendered or initiated
- the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.
If you receive correspondence about your Medicare billing from the DoH, seek advice and support from your medical defence organisation.
What else should GPs know?
You are responsible for all billing under your provider number, including any debts to Medicare (subject to the
Shared Debt Recovery Scheme).
If Medicare billing is unable to be substantiated in the Professional Services Review, you are required to repay the full amount to Medicare. For example, if the time requirement for an item 36 is not met, the full amount must be repaid to Medicare, not the difference between an item 36 and item 23.
Complex computer algorithms are set to identify outliers, so most GPs come to the DoH’s attention because their data is statistically different to that of their peers.
compliance Department Of Health item numbers Medicare medico-legal
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