Medicare Compliance: What providers need to know
BY SIMON COTTERELL, FIRST ASSISTANT SECRETARY, DEPARTMENT OF HEALTH
Have you been contacted by the Department of Health or Medicare about your MBS billing? Here’s what you need to know.
The Department of Health is responsible for protecting the integrity of Medicare payments to health care providers. More than $36 billion is paid each year to more than 140,000 providers and 6,700 suppliers through the Medicare Benefits Schedule (MBS), the Pharmaceutical Benefits Scheme (PBS), the Child Dental Benefits Scheme (CDBS), Practice Incentive Program (PIP) and other incentive payments. It is estimated that two to five per cent of claiming may be non-compliant.
The Department aims to support compliance and prevent non-compliance wherever possible through:
- Provider education. General Medicare compliance training materials are available at: <https://www.humanservices.gov.au/organisations/health-professionals/subjects/education-services-health-professionals> and the Department is working with the AMA, the professional Colleges and specialist Associations to develop more tailored approaches for each professional grouping. Since March 2019, the Department has taken responsibility for the AskMBS email advice service – AskMBS@health.gov.au – to provide authoritative advice on MBS schedule interpretation and to ensure consistency with compliance approaches;
- Targeted letter campaigns to alert providers whose claiming patterns indicate they may be at risk of non-compliance. These letters generally compare the individual provider’s claiming to that of their peers and attach a schedule of claims for review. Reviewing the schedule and responding to the letter is voluntary. However, it is in the provider’s interest to do so. In monitoring future claiming and deciding whether an audit or other intervention may be required, the Department will take into account information received from the provider about why they consider their claiming is correct, any corrections to claims and/or any changes in claiming patterns following the letter.
Where these letters attach a lengthy schedule, one approach open to providers is to review a sample of the claims before deciding whether a line by line review is needed.
The Department undertakes the following activities to treat non-compliance:
- Audit, which is generally used to treat potential incorrect claiming. In an audit, the Department writes to a provider requesting documentation to substantiate a set of claims about which the Department has concerns. The letter will indicate the kinds of documents that may be accepted to substantiate claims. If clinical notes are involved, in order to protect patient privacy the provider may redact elements which are not relevant to the claim and/or request that a medical adviser review the documents. Responding to audits is not voluntary. While the initial letter requests a voluntary response, if required the Department may issue a Notice to Produce documents under s129AAD of the Health Insurance Act 1973, and administrative penalties may apply for failure to comply. The Department conducted 153 audits in 2017-18;
- Practitioner Review Program (PRP), which is generally used to treat potential inappropriate practice. Inappropriate practice is defined under the Health Insurance Act 1973 to mean conduct by a practitioner in connection with rendering or initiating MBS services that a practitioner’s peers could reasonably conclude was unacceptable to the general body of their profession. Under the PRP, the provider will receive a telephone call from a departmental medical adviser to let them know that their claiming appears to be significantly different to that of their peers. This is followed by a letter setting out the claiming of concern and an interview to seek to understand the pattern of claiming. Where concerns remain after the interview, the provider’s claiming may be monitored over the following six months or the provider may be referred to the Director of the Professional Services Review (PSR). The Department conducted 421 PRP interviews in 2017-18 and referred 109 matters to the Director PSR.
- Investigation, which is generally used to treat potential fraud. The Department uses investigative approaches common to many law enforcement agencies, drawing on powers under the Health Insurance Act 1973 and the Human Services (Medicare) Act 1973. Where evidence of fraud is found, the matter is referred to the Commonwealth Director of Public Prosecutions (CDPP) for action in the courts. The Department conducted 50 investigations in 2017-18. Court action on 21 matters referred to the CDPP was completed in 2017-18.
The Department seeks comments from the AMA and the professional Colleges and Associations on its compliance activities. The aim, wherever possible, is to support compliance and prevent non‑compliance rather than to address incorrect claiming, inappropriate practice and fraud after they have occurred. These compliance activities support the integrity of the Medicare system and help to ensure that health resources are directed where they are needed to support the health of the Australian population.
Published: 20 May 2019