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Tips to avoid Medicare compliance issues

13 October 2022 | Dr Michael Wright, MBBS, MSc, PhD, FRACGP, GAICD, General Practitioner and Chief Medical Officer, Avant

Medicare is complex and it can be difficult keeping up to date with new and changed item numbers. The overwhelming majority of doctors want to do the right thing and bill Medicare appropriately and in accordance with the rules. There are several common errors that can catch practitioners out. Here are our top tips to manage Medicare billings and help avoid compliance issues.

1. Understand the item number

As the provider you are responsible for claims to Medicare made under your provider number. You need to be sure you are applying the correct item numbers and that your consultation with the patient covers the elements required for you to charge that item number.

If you are using checklists or summaries, make sure you also have a process to check and maintain these against the full item descriptor in case of updates. Check with the government email advice service askMBS if you are unsure.

Urgent after-hours item numbers are often an area for confusion. If you are using these numbers it is important to check the requirements of the item number. Make sure your documentation reflects your judgement that the patient did need urgent medical assessment after hours.

2. Keep careful records

Keeping appropriate medical records for all patients is a legal and professional requirement. It is also a legal requirement when you make a Medicare claim for a service that you maintain an adequate and contemporaneous medical record that demonstrates the service was provided.

Inadequate medical records can result in an audit finding that the benefit for those services should not have been paid, and the government will seek repayment of the full amount of the Medicare benefits paid.

To satisfy Medicare requirements your records need to identify the patient and include a separate entry for each attendance by the patient for a service.

Be sure to record enough details that explain why the service was needed, the clinical input you provided and why the particular item number was billed. Very brief notes such as ‘script written’ with no record of presenting complaint or patient history or examination are likely to be questioned.

    At a minimum, ensure you address:
  • Reason for presentation
  • History
  • Examination
  • Investigations
  • Diagnosis (provisional or final)
  • Management plan
  • Time spent – if the item number has a minimum time component make sure you record the time spent either in the progress notes or in your medical record-keeping system. The time recorded should be the time you and the patient spend in the consultation, not the time the record is open. It is not enough just to select the item number for that consultation length.

3. Check all billings made under your provider number

You will be accountable for all services billed under your provider number and you are expected to make the decision about which item numbers to claim.

It can be helpful to have hospital or practice administrative staff submit claims for you but make sure the process allows you to check and approve any claims billed under your number.

If you are concerned that your provider number may have been used to make incorrect claims, contact Avant.

Claims can be audited after you have left your current practice, so keep a copy of all reports of claims submitted under your number for two years in case any are questioned in future.

4. Be confident the service is appropriate

While acknowledging that most providers do the right thing and that most errors are inadvertent, the government has indicated it will identify inappropriate or fraudulent claims.

For example, recent Medicare reviews have focused on item numbers relating to care plans. PSR committees have expressed concerns about practitioners’ unusually high use of care plans, chronic disease management plans and team care arrangements.

It is appropriate to recommend a plan to a patient who you feel will benefit. However, you should not seek to recruit patients to care plans without the appropriate clinical basis. Make sure that any plans you create are clearly tailored to the patient, that they identify the disease, document a baseline assessment or individualised goals, and document patient consent.

5. Keep up to date with peers and ask for feedback

Medicare requires that services billed are clinically relevant. One way to be sure you satisfy this requirement is to keep in touch with peers and ensure your practice is in line with commonly accepted standards.

Medicare reviews check for statistical outliers and anomalies. Being aware of your peers’ practices can help ensure your Medicare billing is consistent, or that you are aware of and can explain any differences. Also ask practice staff to let you know if they think your practice does not align with their expectations or if they think you have made a mistake.

However, as noted above, check the item numbers yourself and don’t rely on hearsay or ‘corridor advice’ as to what you should be billing.

Conclusion

It is crucial to be familiar with and to satisfy the requirements of any item number you bill. Item numbers can change, and there is an ongoing review process through the MBS Continuous Review to ensure the MBS continues to support high-quality care and is up to date. By following the principles of good practice you will be better placed to address any concerns and avoid scrutiny of your billings.

References and further reading

Department of Health - AskMBS Email Advice Service

Avant resources - Medicare: what you need to know

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