Medicare compliance is ramping up: What GPs need to know

Sara Bird

20/08/2019 1:30:50 PM

The Department of Health is cracking down on Medicare compliance. Medico-legal expert Sara Bird has some recommendations to help GPs.

MBS online
The Government recently announced it would spend $9.5 million over five years to improve Medicare compliance arrangements and debt recovery.

In the case files that we have opened over the past week, one third of all new investigations were related to Medicare.
That’s unusual. Normally, that figure is only 10%.
It’s a sign that the Department of Health (DoH) is ramping up its scrutiny of Medicare billing.
In May last year, the Government announced it would spend $9.5 million over five years to improve Medicare compliance arrangements and debt recovery. This is now resulting in a greater volume of Medicare audit and review activities for GPs and other specialists.
We can see the results in the Professional Services Review Director’s Updates. In June, a GP agreed to repay $428,000 and was disqualified from providing some Medicare Benefits Schedule (MBS) items for 24 months and other items for 12 months.
Of note, and perhaps of some reassurance to GPs, there has recently been increased scrutiny of specialists other than GPs. For instance, the July Professional Services Review Director’s Update includes a report of repayment of $1,186,093.05 by a consultant physician in respiratory and sleep medicine.
MBS items commonly being reviewed include chronic disease management services (especially team-care arrangements where the requirements to meet the item descriptor are quite specific), mental health plans, after-hours items and skin cancer items. You may also come under scrutiny if your ratios are well outside those of your peers (eg items 23:36 or 23:44).
Types of DoH activities:

  • Targeted letter campaigns and voluntary self-audits, such as the ‘Review and Act Now’ letters
  • Compliance audits – these are designed to ensure benefits are being paid in accordance with the legislation, and may involve the mandatory production of documents to substantiate Medicare claims
  • Practitioner Review Program – after being provided with a list of the DoH’s concerns and the relevant Medicare data, practitioners are then asked for an initial interview with a peer. This interview may result in the DoH’s concerns being addressed with no further action, ongoing review of Medicare data following a period of review, or potentially a referral to the Director of the Professional Services Review
  • Professional Services Review – where the Director initially undertakes a review of the GP’s provision of services to consider if there is a possibility of ‘inappropriate practice’ (defined as conduct in connection with rendering or initiating services that a committee of peers could reasonably conclude was unacceptable to the general body of GPs) or breaking the 80/20 rule (rendering 80 or more professional attendance services – not patients – on 20 or more days during a 12-month period)
What can GPs do to avoid problems?
First, know the MBS item descriptors. Ensure you read and understand the MBS descriptors for the items you bill. If uncertain, seek advice from your medical defence organisation or
Make sure you keep adequate medical records. ‘Inappropriate practice’ may be found where you have provided the service but your medical records are found to be inadequate. The legislative standards for ‘adequate and contemporaneous’ medical records are that:
  1. the record must include the name of the patient
  2. the record must contain a separate entry for each attendance by the patient for a service
  3. each separate entry for a service must
  1. include the date on which the service was rendered or initiated
  2. provide sufficient clinical information to explain the service
  3. be completed at the time, or as soon as practicable after, the service was rendered or initiated
  1. the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.
If you receive correspondence about your Medicare billing from the DoH, seek advice and support from your medical defence organisation.
What else should GPs know?
You are responsible for all billing under your provider number, including any debts to Medicare (subject to the Shared Debt Recovery Scheme). 
If Medicare billing is unable to be substantiated in the Professional Services Review, you are required to repay the full amount to Medicare. For example, if the time requirement for an item 36 is not met, the full amount must be repaid to Medicare, not the difference between an item 36 and item 23.
Complex computer algorithms are set to identify outliers, so most GPs come to the DoH’s attention because their data is statistically different to that of their peers.

compliance Department Of Health item numbers Medicare medico-legal

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newsGP weekly poll Would the reintroduction of MBS items for GPs to trace and report on electrocardiogram (ECGs) be beneficial to patients?



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Graeme Banks   21/08/2019 7:58:25 AM

Whatever happened to the original promise that rebates would always increase with the CPI figures?
The slow death of General Practice.

DS   21/08/2019 8:02:38 AM

I feel that GP’s can be easy targets inspite of claiming lot lesser compared to specialists. Inadequacy on notes can be applied to any set of notes if dug deep enough. GP see wide variety of presentations and to have perfect set of notes is not practically possible in that short period of time. Just my thoughts.

SSC   21/08/2019 11:18:25 AM

GP’s are unfairly targeted in proportion to other specialists . We are at the coal face and the disrespect for our profession is only growing. Why would any intelligent doctor in training choose General Practice ... despite the “specialist in life” campaign no one believes our job is worthwhile as highlighted by the MEDICARE freeze and poor rebates for our work.

Parveen Kumar   21/08/2019 5:01:54 PM

I believe for a GP each presentation is kind of complex presentations and when it comes to billing majority of items claimed are standard visit though time consumed with each and every patient including documentation invariable go beyond 20 min even for simple presentations.

Dr Richard Waluk   26/08/2019 6:05:57 PM

Looks like we are back to the infamous Dr Tony Webber's time with the flurry of audits which in the end shown before the Parliamentary Inquiry to be nothing but "a fishing expeditions" aimed at propping up Medicare budget. Then the Audit of the results confirmed that bad GPs were infrequent and that audits costed many milion dollars more than PSR projected and only pumped a lot of public money into "investigators" pockets. Dr Webber "was not re-appointed" as the result... Did they forgot these lesson?

I P   26/08/2019 10:39:37 PM

How on earth a doctor can listen to the patient examine,explain possible diagnosis Arrange investigations if need and do scripts
And document all in 10 min.
When they do audits they expect all 10 min items full fill these criteria. Lot of GPs stay extra 1-2 hours at work to meet these Medicare definition documentations with out any payment . No one is talking about that unpaid 7- 8 hours every week.Doctor patient relationship is a human intersection-unable rush as Medicare expected.

Shivani Moodley   31/08/2019 11:00:56 AM

Yep, we are the problem rather than recognizing the complexity of the what it means to manage health in the 21st century and fit it to the confines of an outdate model of a consult descriptor. They are trying to push GP’s to privately bill and look like greedy pariahs. We should all go on strike.

David   31/08/2019 11:28:29 AM

Some dubious advice in this article. Do NOT rely on askMBS. They give inconsistent answers or non-answers, and the PSR has over-ruled their advice on many occasions.

Ben   1/09/2019 12:15:30 PM

Colleagues, the answer to our financial woes is not to sail close to the wind with billing practices but to improve the amounts rebated to patients for our services - and to charge the patient a fair amount. Too many of us are complaining here about the MBS rightly checking for irregularities and rorts. But the integrity of the system is critical. We need not fear checks.

Dr A   2/09/2019 2:05:45 PM

Interestingly, only doctors are scrutinised how about the cowboys- the big bosses who sits behind the glass doors, collecting far more for the amount of work they do? Similarly how about the trendies who collect money like after a storm people collect free fruited from the tree? These people charge triple of the amount we charge for the let’s say 10 mints appointment? On top of that, they take cash in hands. There is no agency to punish them for their cruelty hence has free hands. Look at the efforts and time doctors spend during there student years and for the life long journeys to keep the professional skills uptodate- just a thought to share...

John-Paul Kennedy   3/09/2019 11:45:52 PM

This comment section should be closed to cowards who wish to air their xenophobic views about overseas-trained doctors from the comfort of anonymity.
Keep your bigotry behind closed doors where shameful things belong.
Let's have real name tags for the comments section and keep this muck off our college discussion forum.
Simple solution.

Joe   9/09/2019 2:47:35 PM

GPs don't need to know what they already know. RACGP needs to lift up its game. Other wise there is no need to waste 1000 plus every year in membership fees.

Dr Roger John William Parrish   26/09/2019 9:43:39 AM

I have been a GP with a fellowship in Sports Medicine, in a practice I started 50 years ago. I finally retired this month. The modernization of a GPs. way of practicing medicine is both wonderful and depressing as far as I am concerned. Wonderful in what can be achieved with investigation and treatment and depressing with the onus that is put on GPs with their recording, reporting etc. I am a 1 finger typist who never had a mobile to continuously practice on as a teenager so recording notes on a computer is very laborious and time consuming. DRAGON was a great help! Clinical acumen seems to be replaced by multiple investigations to reach a simple diagnosis. 1984 has passed but Big Brother has increased dramatically!