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Nearly 600 GPs to be sent Medicare compliance letters


Anastasia Tsirtsakis


7/02/2023 4:26:09 PM

The latest campaign relates to co-claiming of chronic disease management and practice nurse support services.

GP looking through documents.
Recipients of the latest compliance letter have until 17 March to review their claims.

Hundreds of GPs have been sent a letter from the Department of Health and Aged Care (DoH) this week as part of a new compliance campaign focused on Medicare claiming.
 
Sent on behalf of the Assistant Secretary of the Compliance Audit and Education Branch, the letters are being sent to GPs who have co-claimed practice nurse item 10997 and a chronic disease management (CDM) item for the same patient on the same day, between 1 March 2021 and 28 February 2022.
 
‘While claiming these items on the same day is not restricted, the department considers that item 10997 would not routinely be claimed at the same time as a CDM item,’ the letter, sighted by newsGP, states.
 
‘Medicare benefits are only payable where both services are clinically relevant, and the full item descriptor of each service have been met.’
 
According to the latest guidance from the DoH, MBS item 10997 can only be claimed where a GP Management Plan, Team Care Arrangement or Multidisciplinary Care Plan is in place – and for a maximum of five services per patient in a calendar year.
 
The item is for a practice nurse or Aboriginal and Torres Strait Islander health practitioner to provide the following, on behalf of a medical practitioner:

  • Checks on clinical progress
  • Monitoring of medication compliance
  • Self-management advice
  • The collection of information to support GP/medical practitioner reviews of care plans
However, while the DoH states that it would ‘not be expected’ that item 10997 would be routinely claimed on the same day as items 721 or 723, the practice nurse item can be used between structured reviews of a care plan by the patient’s usual GP.
 
It is therefore anticipated that many of the claims GPs are being asked to review may be in fact be valid, putting the onus on clinicians to justify their billing.
 
Dr Cathryn Hester is a member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR).
 
She told newsGP that while the RACGP acknowledges the need for ‘oversight and accountability’ when it comes to Medicare compliance, the college is continuing to advocate for members in this area, highlighting that letter campaigns can be ‘harmful’.
 
‘Unfortunately one of the … levers that DoH is increasingly relying on is the use of large volumes of poorly targeted compliance letters,’ Dr Hester said.
 
‘I say “unfortunately” because it is my opinion that compliance letters do not form part of what I would consider education or supportive reference material and can be very harmful for GP wellbeing.’
 
The RACGP has been in contact with the DoH, who confirmed that 596 GPs are expected to receive a compliance letter as part of the campaign.
 
While the DoH did not clarify how many potentially non-compliant claims each GP recipient has made, the college is aware of GPs being asked to review hundreds of claims in the space of a few weeks.
 
The RACGP is calling for the Federal Government to take a more targeted approach with its compliance interventions by finding a way to exclude valid claims, and for greater access to clear reference materials and education to be available for GPs to help guide appropriate MBS usage.
 
‘This is especially important for item numbers that have some ambiguity, like care planning item numbers,’ Dr Hester said.
 
‘We all want a fair system, where patients have access to appropriate rebates, and GPs are able to operate without fear of unnecessarily punitive actions, and there certainly is a place for systems to help monitor this and ensure the appropriate usage of public funding.
 
‘Recently there has been a move by DoH to provide simple and clear advice in MBS reference handouts, especially around some of the more confusing topics like Hospital in the Home Care. I think this is a move in the right direction.’
 
Medicare compliance is an ongoing issue for GPs and other clinicians in Australia. According to the most recent Health of the Nation report, almost two-thirds of GPs (61%) indicated that the complexity of Medicare is something that worries them outside of their work day, and this was much higher among GPs in training (80%).
 
But Dr Hester said that for the most part, she has been struck by how GPs are a ‘very conscientious group’.
 
‘With very few exceptions, we bill very conservatively, and we “stay between the lines”,’ she said.
 
‘When we deviate from what our cohort is doing, it is usually either because of a lack of understanding – and the MBS system can be very convoluted – or we are trying to meet exceptional demands from our communities.
 
‘It is very rare to see examples of predatory MBS item billing, as we know from the very low rates of negative PSR outcomes. I would implore the DoH to consider this in their planning for further GP interventions – and to also consider the potential harms of any scattergun compliance approaches to the communities that GPs serve.’
 
The DoH has given recipients of the compliance letters until 17 March to review their claiming of the listed items and to respond.
 
For further information on billing chronic disease management and practice nurse support services, there are a number of educational materials that members can access: Members can also access the RACGP's statement on Medicare interpretation and compliance.
 
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SD   8/02/2023 8:18:51 AM

This is one of the big reasons there are lesser GP’s working full time, lesser junior doctors joining general practice. It will never be easy to match medicine with an item number.


Winston Smith   8/02/2023 8:42:50 AM

OK, another ill-conceived attempt at a nudge letter by DoH. Firstly, for those who are rorting this item number, shame on you. But for the vast bulk of decent GP’s this is yet another slap in the face. Could the RACGP please write a form letter and provide this to all members that goes like this…”Dear DoH, thank you for your recent nudge letter. I take this seriously. A review of my billing has shown no irregularities. This has taken considerable time and effort (and caused much stress). To recoup this time and loss of income, I have now decided to completely abandon bulk billing my patients. Thank you, etc.”
If DoH gets hundreds of these letters (that are also cc’d to the Health Minister) then they might think twice about these ham fisted attempts at justifying what amounts to institutional bullying.

It’s about time GP’s “nudged” back.


Dr Greg Saville   8/02/2023 8:47:19 AM

My very limited understanding of contract law is that any ambiguity in a contract (and there is one between a GP and Medicare) goes in favour of the person signing the contract (the GP). It is contingent upon Medicare to remove any ambiguity in item numbers to ensure fairness and transparency in the contract GP’s have entered into.


Dr Nicholas A. Cooper   8/02/2023 7:01:08 PM

When attempts to get a straight answer from MBS Online or askMBS result in encountering phrases such as 'It would not be expected', or 'is not intended to be used', or 'is intended to be used', it's no wonder we get bamboozled. Why don't they give a straight answer that something is allowed or not allowed


Dr Risto Cvetkovic   11/02/2023 12:41:47 PM

I received a call back from Medicare compliance staff (she was polite and sounded very inexperienced in how these CDM and nurse items numbers are being applied in GP practice ) after my written request for further clarification. She told me they have "internal departmental rules" that are not published and therefore not available for GPs to follow ?!!! And that the cut off number for this compliance reveiw was 300 (so. 299 episodes of co-claiming was considered acceptable to Medicare). I was also told that the reason item 10997 "is not intended to be billed" with CDM items is because "the work a nurse does to help doctor" create a GPMP, TCA, the review of either or MCR for NH pts is already included in these CDM items". That implies that to be able claim CDM items, GP has to have RN involved - and I queried Medicare how is it then fair to practices that don't have a nurse, but the response is that if RN helps GP in generating CDM - Medicare won't pay for it.


Dr Nicholas A. Cooper   24/02/2023 7:19:32 PM

Having had the meeting with the Assistant Secretary of the Medicare Compliance Branch and his team, we appear no closer to a resolution despite only having 3 weeks to answer the DOH letter. The only interpretation I can make is that I should not have claimed a 10997 on a patient who has never had a Care Plan so long as the Practice Nurse has met the criteria for claiming a 10997 acc to AskMBS which differs from the DOH suggestion that you cannot claim this item with Care Plans. We need clarity