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Five tips to stay on the right side of Medicare

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

Wednesday, 12 October 2022

5 tips for medicare

The learning curve for Medicare can be steep when you are finding your feet in private practice and providing different services from those offered in the hospital system. However, there are several common issues that can catch practitioners out.

Follow our tips to help you avoid concerns being raised about your Medicare billings.

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.

Tips

It can be helpful to use a checklist to make sure the service meets the item requirements.

However, descriptors do change so find out what the process is for checking and update summary versions. Some of the descriptions can be quite nuanced, so it is a good idea to go back to the full item descriptor to make sure you understand the requirements. Check with the government email advice service askMBS if you are unsure.

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 a finding that the benefit for those services should not have been paid. The government will seek repayment of the full amount of the Medicare benefits paid for the service.

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 the presenting complaint, 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 in the consultation

Tips

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. It is not enough just to select the item number for that consultation length. The time recorded should be the time you and the patient spend in the consultation, not the time the record is open.

‘Urgent’ after hours item numbers can be an area of confusion. If you are using these numbers, it is important to check the requirements of the item number. Make sure your notes reflect your judgement that the patient did need urgent medical assessment after hours.

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.

Tip

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

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

Medicare requires that services billed be clinically relevant. This is determined by what is acceptable to your peers, so it is important 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 also help ensure your Medicare billing is consistent, or that you are aware of and can explain any differences. When you are new to a practice, check your billings with practice staff or ask them to let you know if they think you have made a mistake.

Tip

As noted above, make sure you check Medicare item numbers and descriptors yourself and don’t rely on hearsay or ‘corridor advice’ as to what you should be billing.

5. Be confident the service is appropriate - and take special care to record referrals

As well as items 132 and 133, items 104 and 110 have been a focus of PSR reviews involving multiple specialities.

  • The PSR has flagged that these items require an actual consultation with the specialist whose provider number is being used. Concerns raised in relation to these item numbers included:
  • Lack of evidence of a referral requesting a specialist consultation.
  • No record of inadequate records of an attendance or patient consultation.
  • Lack of clear clinical indication for the consultation.
  • Inadequate communication of consultation outcomes to the referring practitioner.
  • Co-billing a consultation with a procedural service when the record did not support a separate consultation being performed.

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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