Claims and medico legal queries - Medicare
Summary: 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.
Sunday, 23 October 2022
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:
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)
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
Most common MBS item numbers rendered that did not meet accepted standards or requirements:
723 team care arrangements
721 preparation of GP management plan
732 review of GP management plan/team care arrangements
132 Initial assessment, at least two morbidities, minimum 45 minutes
133 subsequent attendance, at least two morbidities, minimum 20 minutes
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).
- 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.
- Claims refers to claims for money, compensation and civil claims.
- Medicare claims include Medicare investigations and audits.
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