How can GPs stay safe amid increasing scrutiny of billing?

Nerissa Ferrie

4/09/2019 3:26:49 PM

Medico-legal adviser Nerissa Ferrie has a few tips on how to bill appropriately and stay protected.

Using MBS online
With more than 5700 item numbers, it is little surprise an individual GP can have difficulty navigating MBS billing.

Why is it so hard to know how to bill Medicare correctly?
Consider the fact the Medicare Benefits Schedule (MBS) Review Taskforce needs more than 70 clinical committees to review each area of MBS-supported clinical practice, and it has taken three years and more than 700 clinicians, consumers and health system experts to provide detailed advice on how to improve the MBS and keep the items and the descriptors up to date.
No surprise then, given the MBS contains more than 5700 items, that it would be incredibly difficult for any one person to be across every individual item.
It is understandable that GPs may be concerned in light of recent news that Medicare compliance efforts are increasing, particularly if they feel there is a lack of clarity regarding items.
While many GPs worry about a possible issue with the Australian Health Practitioner Regulation Agency (AHPRA), I believe billing can be more stressful.
Why? Because repayments for overbilling are not covered by professional indemnity insurance, and few people have cash sitting in reserve just in case they are audited.
At MDA National, we have seen a recent increase across the board of compliance activity, including ‘Review and act now’ letters, compliance audits, data analysis through the Practitioner Review Program, and referrals to Professional Services Review.
I have worked in this area for 10 years and the data analysis provided by the Department of Health (DoH) has become more sophisticated in recent years. It seems the DoH has picked up the more obvious statistical outliers. Now they are drilling down to the next percentile.
The obvious conclusion is that the amount the DoH is recouping is outweighing the cost of those audit processes. This means doctors need to be much more aware, particularly if they have been interpreting some items more generously.
I would urge GPs to now be much more certain of what the MBS descriptors say and ensure they are billing accordingly. When doctors are under the Practitioner Review Program or Professional Services Review, I have found that very few are completely confident their billings will withstand such intense scrutiny.
Billing ratios are being raised more often, which is a sign of the increased sophistication of the DoH’s analysis tools.
In some Practitioner Review Program letters, an area of concern may be timed item ratios – how many Level B consultations you bill versus Level Cs. They will quote the national average and then provide your ratio.
When the DoH runs audits, they pick up the outliers, GPs who are billing much more than their peers for specific items. GPs with a specific interest or sub-specialty thus have to be particularly careful.
GPs who regularly bill a less common item because it is an area of professional interest have to make sure they are entirely on top of their billing because they are more likely to be flagged than someone whose items are more evenly spread.
So what should GPs do?
The AskMBS helpline is a good first step in seeking clarification.
In my view, there is always a concern that something may be lost in translation when clinical interpretation is involved. This doesn’t just apply to the DoH, but would apply to anyone giving advice on Medicare billing.
Conversely, some items are so straightforward that there is no other way to interpret it other than repeating what the descriptor says. This may appear unhelpful, but there is simply no other way for the DoH to say it.
I would expect that the DoH receives a fair number of hypothetical questions through its AskMBS helpline. If the question includes several ‘what ifs’, those questions can be extremely difficult to answer. I have found that a simple, but well-worded, question will be more likely to result in a clear answer.
Unfortunately, it is not uncommon for clarity about the item descriptor to only be achieved during the audit process.
This can be frustrating for doctors who may think they are billing the correct item and then become aware this is not the case when they seek assistance from their medical defence organisation following correspondence from the DoH, or during the telephone interview with one of their medical advisers.
I have noticed, however, that many of these doctors have never contacted AskMBS to seek clarification early on.
Most billed items that are repaid through a compliance audit, the Practitioner Review Program or the Professional Services Review, are the result of doctors either not reading the criteria for billed items, failing to meet all aspects of the descriptor, or not making adequate medical records of the consultation.
Medicare is a black-and-white jurisdiction in the eyes of the Government, so ignorance is not accepted as an excuse for billing the incorrect item number.
Common issues
Misinformation can be a problem, such as when a GP who has recently achieved Fellowship relies on what their colleagues tell them. An older colleague saying to do it a certain way because they have never had a problem can be a real issue, because it results in new GPs thinking they are doing the right thing.
Every doctor has a responsibility to ensure they are billing correctly. That can mean deciding not to bill an item even if their practice tells them to or because their colleagues do it. Billing correctly also means avoiding billing higher value items simply because dealing with a certain cohort of patients is particularly difficult and time consuming.
Some of the problem areas for GPs we regularly come across as medico-legal advisers include chronic disease management items, after-hours billings, ratios (B:C or B:D), mental health care items, items in association, and prescribing.
There is no magic in the descriptors for any of these items, and most do not require explanation because the descriptors are quite clear. In fact, the item numbers may often be correct and the issue is instead that the medical records simply do not support the billings. This is not something that can be solved by sending an email query to AskMBS.
How can GPs make sure they are billing appropriately?
Each specialty should ideally have a very good understanding of the top 10 items they regularly bill, and routinely consult the MBS to ensure they are billing those items correctly.
If there is a significant issue with the interpretation of a particular item, such as the anatomical debate over item 18234 (injection of an anaesthetic agent into a primary division of the trigeminal nerve), in my view it is better for the relevant college to liaise with the DoH and ask the question on behalf of the specialty, rather than individual doctors all making contact independently.
If a GP contacts AskMBS for clarification on an item, I would advise to keep all written responses in a safe place in the event they need to rely upon the DoH’s written advice down the track.
We have had doctors who say they were told one thing five years ago only, to be audited and told that the information is no longer correct. Unless you get that earlier advice in writing, you could be in trouble.
In summary, it is time to be very clear on MBS billing.
Understanding the written descriptors, keeping good records, and checking independently rather than relying on accepted wisdom are the best ways to avoid problems.

billing compliance Medicare medico-legal

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Dr Claire Elizabeth Cupitt   5/09/2019 8:19:37 AM

Like many doctors, for years, I thought the audit/PSR process was inherently fair and only those doctors who were overtly rorting the system got picked out. Having been closely associated with a case, I now realize that "the system" is not fair, nor transparent, and is a law unto itself, and is hurting general practice . We, doctors, and especially GPs need to stand together and be supportive of each other.

Dr Brahmanandan Malapurathattil   5/09/2019 8:45:59 AM

Not educative just re_empfasising what is already known

Dr Nazareena Essop Ebrahim   5/09/2019 9:23:55 AM

Can the college not then run educative sessions in this area...

Michael Rice   5/09/2019 9:33:59 AM

I look forward to a follow-up articles "How can GPs stay profitable amid increasing scrutiny of billing and the rebate freeze?" and "How can GPs legally derive additional cashflow while delivering bulk-billed services (as co-ops can)?"

Andrew   5/09/2019 10:43:25 AM

It would be helpful if the department were required to provide, on request by a GP, a standardised pro forma statement of their current billing including for example the item number "ratios" referred to, with a national yardstick comparison information (similar to reports from the NPS etc).
This would need to be available on a without prejudice basis (just because you ask for a report it doesn't mean you think your are guilty), and would enable GPs to be informed about where they stand from the department's perspective and self monitor over time - rather than the very confronting problem of just receiving a please explain letter one day in the mail.

Chris Hogan   5/09/2019 2:59:18 PM

I have worked in General Practice since 1978 & been involved in medical politics since the late 1980s. I cannot decide if I am cynical or experienced - probably both.
I am convinced that governments of all persuasions only see Medicine as a cost that they are trying to reduce rather than an investment in the health & productivity of the nation.
They seek to turn us into a caste of bulk billing serfs but not content with that they use confusion &!weasel words to scare us into billing the minimum for every consult
So analysis shows that not all GPS practice in the same way!
News Flash! We never did & please God - we never will! We are neither clones nor sheep but deliver what our patients need
We have two choices -stop bulk billing or have all of us become employees - hang on, are not 60% plus of us already employees?

Lindsay   5/09/2019 7:58:49 PM

Wise words, Chris Hogan. I do wonder why we ( the College) allow the Government to back us further into a corner with their inadequate financing of general practice. All the politicians ever talk about is hospital funding, when all the evidence shows that a good relationship with your GP is much more likely to keep a person out of the hospital system. So why do they continue to promote large practices where the patient is lucky to see the same doctor twice, & probably only for 10 minutes at a time? Why are those of us that see our patients year in, year out, & take the time to listen, examine & advise our patients, being constantly penalised, especially if, God forbid, our patients do not have the extra cash to pay out-of-pocket to see us?
My income has dropped year by year ever since 2013, & I'm not convinced that the College is really advocating for me. Thank goodness I'm on the cusp of retirement, though I worry who will take care of my patients when I'm gone?

Marc Heyning   6/09/2019 7:39:59 AM

AskMBS does NOT have a good reputation amoung practice managers. According to a Practice Manager forum, emails to AskMBS take 2-4 weeks to be answered and by then, the question is mute/past-tense. Telephone enquiries are quicker but result at times with different answers depending on which MBS staff is answering. Our practice does ring for clarification and then documents 'what was said' by 'whom'. Imperfect but better then AskMBS

Farzana Mitra   7/09/2019 8:49:23 AM

The hounding of GPs by AHPRA, Medical Boards, ministers and Government Agencies has driven down the number of doctors in training for general medicine. Not to mention the lowest earning of any speciality in Medicine and government squeezing it dry. This is despite the fact that good investment in primary care drives the costs of hospital care down. Research has shown that good primary care and education prevents patients having complications and ending in hospitalisation and early deaths. Perhaps it is not what they want??

SD   7/09/2019 9:35:39 AM

The audits and huge sums of fines imposed has led to change of practice among the GP’s. I know of a GP practice shutting down as a result of enormous fine and many GP’s are practicing under a fear of an audit. People caught in this process say that there is no defence. More auditors are getting hired as it is raising more money in fines. A GP should be more worried about patient care and missing clinical issues rather than fear of a huge payback for the work done and taxes paid for that work. One suggestion for a solution to stop rotting is to make General Practice an employment with hourly pay and employee benefits of leave entitlements. A practice gets certain fixed amount from Medicare for hiring a GP. Then there is no scope for incorrect claims.

James   7/09/2019 10:38:33 AM

We should be judged by our peers, not the pseudo GPs or ivory tower dwellers that seem to be involved.

Bill Meyers   8/09/2019 10:36:18 PM

I agree with Chris and Lindsay,
I have been audited, back in the "good old days", and threatened with de-registration, for looking after a cohort of patients that are poor and sick. My College (not RACGP ) stood up for me, and prevented me from being de-registered. That College is the Australian Medical Acupuncture College. Medical acupuncture has been shown to reduce costs to both patient and Government, whilst reducing contemporaneous mortality rates (Everybody dies in the end, of course) . The Government, via Medicare, directly penalizes patients who use medical acupuncture, by differentially applying the "freeze" and the "thaw" to rebates, and directly penalizes doctors, by targeting them for audits, not allowing patients access to appropriate rebates whilst the doctor is training in medical acupuncture, and then delaying patient access to those rebates once the doctor has completed training.
"There is no such thing as gravity -the whole Earth sucks" (Apologies, not Chris et al)