How can GPs stay safe amid increasing scrutiny of 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