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Medicare Shared Debt Recovery Scheme: joint responsibility for debts

17 October 2019 | Marianna Kelly, Mast Risk Mgt, Registered Nurse, Grad Dip Dispute Mgt, Dip Prac Mgt, Fellow AAPM, Risk Adviser and Rocky Ruperto, LLB (Hons), LLM, BSc (Psych), GradDipLegPrac, Legal and Policy Officer, Avant

The Shared Debt Recovery Scheme commenced on 1 July 2019, as part of an increased focus to improve debt recovery from Medicare compliance activities. The scheme was introduced because Medicare billing was often delegated to non-practitioners, leading to incorrect billing practices in some instances. With the scheme now in effect, it’s important for both doctors and practice owners to understand Medicare Benefits Schedule (MBS) billing requirements.

Liability of practice owners

Under the scheme, practice owners can be liable for Medicare debts owed by doctors who are contracted or engaged to work within the practice.

Medicare has the power to apportion debts arising from false or misleading statements (e.g. an incorrect claim for a benefit under the MBS) between the individual doctor and a secondary debtor, such as a practice or corporation.

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

  1. Practice could have controlled or influenced the circumstances that led to the false or misleading statement.
  2. Practice directly or indirectly, obtained a financial benefit from the false or misleading statement made.
  3. Circumstances of the case make it fair and reasonable for the determination to be made.

When a doctor is first contacted about an audit, they will be asked if they would like to be considered for a shared debt determination. The doctor will be asked to produce documents for the services claimed and information about relevant employment, contractual or financial arrangements. If a possible secondary debtor is identified, they will also be asked to provide information.

A shared debt determination will be decided by the Department of Health’s audit officer. They will decide whether a debt is owed and if it should be shared between the two parties. The default split is 65% for the doctor (the primary debtor) and 35% for the practice or organisation (the secondary debtor). However, the parties can make submissions if they believe the proportion should be different.

Either party can apply for a review of the decision, which will be undertaken by a review officer, on behalf of the Chief Executive Medicare.

Practical tips to mitigate risks

Practices should document a clear policy on the Medicare billing process in agreement with all doctors and the practice team. The policy should outline that individual doctors are responsible for ensuring the accuracy of their billings.

Recording Medicare item numbers

The doctor whose provider number is being used to charge Medicare, is responsible for instructing which item number is billed. Practice staff should not change the item number themselves.

All communication regarding Medicare billings should be documented via the appointment book, email or an internal messaging facility and any changes should be recorded by the doctor.

Documentation

In order to bill correctly, both individual providers and practices with administrative responsibility for Medicare billings, should ensure medical records:

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

Interpreting item numbers

If you notice a level of variance in the way particular item numbers are being applied, practice managers could encourage a discussion of these item numbers at practice meetings. This will help doctors stay consistent with the standards of practice amongst their peers.

Any concerns practice management have regarding the billing of Medicare item numbers, should be discussed with the doctor (or other provider) and the discussion documented.

If doctors need assistance interpreting MBS items and rules, practice managers could also suggest contacting the Department of Health’s advice service at: askMBS@health.gov.au

Submitting bulk billing claims

Prior to submitting Medicare claims, a report should be provided to each doctor listing the claims for submission. Each doctor should provide their signed and dated authority and copies be retained by the practice and individual doctors.

If a claim is rejected, it should be returned to the relevant doctor. Practice staff can resubmit the claims once the doctor has given authority to resubmit.

More information

Avant made a submission on the scheme to voice our members’ concerns and ensure it is applied fairly for both doctors and practices. Subsequently, the Department of Health released FAQs clarifying the scheme based on our submission. We are also collaborating with the Department of Health to develop educational resources and opportunities for doctors, to address common knowledge gaps and compliance issues.

If your practice receives an audit letter, please contact us on nca@avant.org.au or 1800 128 268 for expert advice.

Listen to our new podcast in which a doctor shares their insights after receiving a Medicare compliance letter.

Watch our video on Medicare compliance insights, download our factsheet on Medicare compliance or complete our e-Learning course, Dial M for Medicare.

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