Avoiding the spotlight: Medicare review

Caroline Tuohey, BA, LLB, Practice Manager Legal (Professional Conduct), Avant Law, VIC

Dr Kelly Nickels, MBBS (Hons) (Monash) MHlth&MedLaw (Melb), Claims Team Manager - Professional Conduct VIC / Senior Medical Adviser

Tuesday, 4 February 2020

Flexible light looking through mist

According to the Professional Services Review’s (PSR) 2018-19 Annual Report1, the total amount repaid by doctors through the PSR was nearly six times the historical annual average. In the last financial year alone, 101 practitioners across numerous specialties were the subject of a PSR review, resulting in the repayment of $29 million in benefits to the Commonwealth.

The consequences of not being able to satisfy the Director of PSR or a PSR Committee that your claiming of Medicare Benefits Schedule (MBS) items was appropriate can be significant and stressful. Here are answers to some common questions from members about the review process and advice on good practices to avoid a review.

How did I become the subject of a PSR review?

The Department of Health’s Practitioner Review Program (PRP) routinely monitors the claiming of MBS items and will contact a doctor if their claiming is irregular compared to their peers. The Department will review the claiming profile of a doctor if its review has identified unusual patterns of item usage or item combinations.

A PRP medical adviser will invite the doctor to explain any ‘concerns’ with the doctor’s billings statistics. If not satisfied with that explanation, the doctor may be offered a period of review to demonstrate changes to their practice before the doctor’s billings statistics are re-examined.

Following this, the doctor may be informed there are no further concerns or invited to make submissions to a delegate of the Medicare Chief Executive Officer in response to issues identified during the review. If the delegate remains concerned about the doctor’s practices, a referral is made to the Director of the PSR who decides whether to conduct an independent review.

Each year, the Department of Health interviews several hundred practitioners to gain further information about their practice through the PRP. A small proportion of these practitioners are referred to the director.

What is involved with a PSR review?

Unlike the PRP review, which only examines the doctor’s claiming figures, the director will review a randomly selected set of patient records for services rendered during the 12-month review period. The director’s team of experienced and currently practising doctors reviews the sample of records and provides a report for the director to consider.

The director will then explain any concerns arising from the review of the sample of records in a letter to the doctor and give them an opportunity to respond.

What are some examples of inappropriate practice?

Inappropriate practice’ is any conduct by a doctor when rendering or initiating services that a doctor’s peers2 could reasonably conclude was unacceptable to the general body of the profession3. This includes keeping medical records that don’t adequately evidence the care provided and billed for.

The key elements of ‘inappropriate practice’ include whether the rendering of the MBS service would be unacceptable to the general body of the doctor’s peers (for example, claiming an item 36 for a straightforward repeat prescription consultation), and whether or not the doctor kept adequate and contemporaneous records for MBS or PBS services they have rendered.

We frequently see two areas identified by the PSR as raising concerns of inappropriate practice – chronic disease management items and items in association.

Chronic Disease Management services (MBS items 721 and 732)

It is not uncommon to see care plans that, on the surface, appear detailed and comprehensive, but are found by the director not to satisfy the requirements of the MBS or otherwise to be unacceptable to peers.

Below is a fictional care plan that includes common areas of concern that are likely to be raised by a PSR Committee:

  • The chronic disease is not clearly identified.
  • There is no baseline assessment or inpidualised goals.
  • The care plan consists of an identical template-driven document with no, or very minimal, clinical input.
  • There is no evidence of patient consent.

Sample GP management plan (item 721) that may cause concern

Patient’s health problems/health needs/relevant conditionsManagement goals with which the patient agreesTreatment and services required, including actions to be taken by the patientArrangements for providing treatment/services (when, who, contact details)
Chronic painIncrease patient's understanding of chronic painPain education/lifestyleGP, physio
PainOptimal pain managementAssessment, monitoring, patient educationGP, physio
General health monitoringMonitoring of general healthReview patient's status, measure BMI, BP, cholesterol profileGP – once every 6-12 months
MedicationsCorrect use of medication, with minimal side-effectsEducation about medicationsPharmacist
Future complications, reduce risk of hospitalisationPrevent/minimise long-term effects of chronic painAnnual complication assessment/adjust medicationConsultant physician
Need for healthy dietMaintain healthy weight and dietIncreasing understanding of healthy eatingDietitian, health promotion officer, GP
Need for physical activityIncrease exerciseEstablish regular exercise routineExercise program of patient's choice
WeightBody mass index (BMI) 20-25Assess and monitor BMI, reviewGP
Psychosocial burden of chronic conditionPrevent adverse effects of chronic conditionAssessment, education, support, referralGP

The expectation of the director is that the goals of the care plan will adhere to the SMART (specific, measurable, achievable, realistic and timely) goals formula.

For example, the director does not consider that a body of GPs would find the goal of 'optimal pain management' to be a GP-level goal. Doctors are expected to provide a SMART goal such as 'increase walking tolerance so the patient can walk to the shops unassisted within six months'.

For reviews of General Practitioner Management Plans, there is often inadequate evidence that a review of outcomes against goals has occurred.

Billing attendance items in association

The second common issue is where a doctor has submitted a claim for two attendance items concerning one appointment. This is because where items are billed together, often there may be a concern that specific requirements of each item, such as minimum consultation times, are not being met or there has been ‘double counting’.

For instance, under billing requirements, where an appointment with a GP for a mental health consultation is being claimed, an additional attendance item for a different health issue can only be claimed if it is clinically indicated and details of the separate issue, history, examination, diagnosis and treatment is identified and explained in the clinical record. As an example, 'patient also complaining of 3/7 sore throat and fever'.

Many records reviewed by the director of PSR concerning a mental health consultation or treatment fail to reflect a separate health problem requiring immediate treatment, often because there is insufficient information provided.

I’m busy, how can my records satisfy a PSR review?

Many doctors feel disillusioned and frustrated by the perception that the director expects very detailed records to support each and every consultation when there are so many demands placed on them.

The director has displayed an understanding that doctors face a challenge juggling provision of care to the patient and maintaining adequate clinical records. From our experience, the following guidelines will assist in meeting the standard for an 'adequate and contemporaneous record':

  • The name of the patient and date of service is clearly identifiable.
  • It contains a separate entry for each attendance by the patient for a service.
  • It provides adequate clinical information to explain the type of service rendered or initiated and to establish that MBS criteria for the item have been met.
  • Each entry is sufficiently comprehensible so another doctor, relying on the record, can effectively undertake the patient’s ongoing care.
  • The record is completed at the time the practitioner rendered or initiated the service, or as soon as practicable after the service was rendered or initiated by the doctor.

Do I meet my obligations if I use templates?

The use of templates is permissible, but unless the template is tailored and specific to the consultation, it will not always satisfy the requirements under the MBS.

We speak to many doctors who utilise templates for various plans and assessments, and a comprehensive template can be very helpful in ensuring that all elements required by the item descriptor have been included. However, unless there is evidence of sufficient clinical input by the doctor, the MBS item will not always be substantiated.

Doctors also use ‘shortcuts’ or ‘macros’ from their medical software programs. The use of these auto-fill functions is permissible, so long as the content is tailored and specific to the presenting complaint.

The director will analyse the content, looking for relevance of a particular examination concerning the complaint. For example, 'heart, lungs examined' may not be relevant to a complaint of an ingrown toenail.

The reliability of templates is undermined if there are repeated sections of text for consecutive consultations.

What are the consequences of non-compliance?

There are three possible outcomes of a referral to the Director of PSR – no further action, negotiated agreement with the director or referral to a committee of the doctor’s peers.

Of the 101 PSR cases, only two were subject to a decision to take no further action and the majority were resolved by way of negotiated agreement.

The outcomes of the negotiated agreements included repayment orders totalling $26 million. In 62 cases, the outcome included partial disqualification from billing certain MBS items for a period and full disqualification from all MBS billing for a period in one case. Repayments ranged from $10,000 to $995,286 with more than two thirds of agreements involving repayments of $200,000 and above.

In most cases, the doctor is required to pay 100% of the benefit claimed even though they may have shared a percentage of the rebate with the practice.

The director also has the power to refer clinical concerns to the Medical Board and increasingly has used that power. This can be particularly problematic when records don’t provide enough detail to explain care.

Under no circumstances should you attempt to improve medical records without clearly identifying when any additions or alterations were made. Metadata embedded in electronic medical records is routinely examined by the PSR to ensure fraudulent alteration of medical records has not occurred.

How can I get across my compliance obligations?

There are many resources available for doctors to get to know their MBS claiming obligations:

  • A good start is to refresh your understanding of the descriptors for MBS item numbers you commonly bill at mbsonline.gov.au
  • For advice about the interpretation and application of the MBS, send any questions to the ‘AskMBS’ team at askmbs@health.gov.au
  • Visit avant.org.au/Resources/Public/Medicare-FAQs for further advice about Medicare compliance and good medical record keeping.
  • The Department of Human Services has detailed training guidelines and e-learning activities on claiming MBS services appropriately at humanservices.gov.au
  • Use the MBS items online checker through Health Professional Online Services.

The responsibility is yours

Ultimately, it is your responsibility to ensure your rendering of MBS services is correct and that the service can be substantiated by your clinical records if reviewed by Medicare.

Regularly reflecting on your billing practices and the quality of your medical records can go some way to avoiding an adverse outcome if you are the subject of a review.

This article was originally published in Connectmagazine, Issue 13.

1Australian Government: Professional Services Review - 2018-19 Annual Report accessed 29/10/2019

2As represented by a Professional Services Review Committee

3Australian Government: Professional Services Review - What is inappropriate practice?

Share your view

We welcome your feedback on this article.

To Top