News
Nearly 600 GPs to be sent Medicare compliance letters
The latest campaign relates to co-claiming of chronic disease management and practice nurse support services.
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.
Log in below to join the conversation.
chronic disease management plan compliance Medicare compliance practice nurse support services
newsGP weekly poll
Which of the RACGP’s 2024 Health of the Nation advocacy asks do you think is most important?