Claims and medico legal queries - Medicare

Medico-legal calls

Calls to Avant’s Medico-legal Advisory Service (MLAS) about Medicare have increased in the last three years, suggesting a growing concern about Medicare. An analysis of topics discussed in MLAS calls about Medicare from May 2021 to April 2022 indicate that compliance activities and COVID related issues were among the key areas of concern.

Top five issues discussed on MLAS calls:

1. Compliance activity e.g. request for advice or assistance with responding to: a compliance letter, Medicare interview, audit, Professional Services Review

2. Provider number e.g. provider number use for nurse-led vaccination program, delays in receiving a provider number, use of provider number without consent, provider number issues due to relocation

3. Billing errors (inadvertent) e.g. errors in billing organised by practice/hospital staff, practice software/billing software errors, how to repay Medicare after inadvertent billing error

4. COVID test or vaccination e.g. how to bill Medicare for large numbers of immunisations, interstate vaccinations, vaccinations for people ineligible for Medicare, item numbers, consultations before vaccinations

5. Telehealth-related e.g. patient consent to billing for telehealth, telehealth when doctor or patient are overseas, permitted number of billed telehealth consultations in one day.

Avant claims related to Medicare

The majority of claims related to Medicare were associated with two main allegations. These were:

54%

allegations of inappropriate practice
including types and volumes of MBS items billed (e.g. Medicare services initiated falling outside the standard acceptable to their professional colleagues)

43%

allegations of non-compliance with Medicare billing requirements (e.g. incorrect claiming)

* Per cent of total Medicare claims shown.
Data source: Avant Medicare claims data closed FY2017 to FY2021

Repayment

Most common MBS item numbers rendered that did not meet accepted standards or requirements:

General practitioners

723 team care arrangements

721 preparation of GP management plan

732 review of GP management plan/team care arrangements

Consultant physicians

132 Initial assessment, at least two morbidities, minimum 45 minutes

110 attendance

133 subsequent attendance, at least two morbidities, minimum 20 minutes

Specialist surgeons

104 initial attendance

105 subsequent attendance

The above review is of routinely collected and coded data. Our review is based on 934 Medicare claims closed over the five-year period from July 2016 to June 2021 (FY2017-FY2021).

Key points

• There has been an increasing number of calls from Avant members about Medicare, with compliance activities and COVID related issues being key areas of concern.
• Avant provided most support and advice about Medicare to GPs and GP registrars.
• The majority of claims related to Medicare arose as a result of allegations of inappropriate practice and alleged noncompliance with billing requirements.
• Half of Medicare claims closed from FY2017 to FY2021 involved a repayment of benefits.

Glossary

• Claims refers to claims for money, compensation and civil claims.
• Medicare claims include Medicare investigations and audits.

Resources

If you receive a claim or complaint, contact us on 1800 128 268 for expert medico-legal advice on how to respond – available 24/7 in emergencies.

For any queries on this analysis, please contact us at research@avant.org.au

You can find additional resources about Medicare, including articles, factsheets, podcasts and webinars in the Avant Learning Centre.