Articles and Case Studies

Take Care with Medicare

07 Nov 2018

by Ms Nerissa Ferrie

Medicare is one of my main areas of interest at MDA National.

With a recent increase in the number of investigations and audits, it seems an ideal time to provide some guidance on what you should do if you receive correspondence from the Department of Health about your billing.

Doctors are often confused and concerned about why they have come to Medicare’s attention. Some doctors feel they have been unfairly targeted by the Department of Health (DOH). In my experience, Medicare investigations tend to be one of the most black and white jurisdictions doctors are subject to.

Put simply, most doctors receive a tap on the shoulder from Medicare because they are statistical outliers. Medicare runs a series of computer algorithms which measures each doctor against every other doctor in Australia. If you are above the 90th percentile for a specific item number, your profile may be reviewed under the Practitioner Review Program.1 Other statistical triggers could be daily billing which exceeds the number of hours in a day, or ratios which are vastly different from your peers, e.g. Level B: Level D. If the anomalies are not readily explained by your practice profile, you may be asked to participate in an interview with a DOH medical adviser. You are more likely to come to Medicare’s attention if you are a specialist with an unusual sub-specialty, or a GP with a special interest which alters your patient demographics.

Certain item numbers may be on Medicare’s radar, and we see some items numbers more regularly than others, including Chronic Disease Management and GP Mental Health Treatment Plans. Each investigation is unique to the individual doctor on the basis of their practice profile.

If you receive a letter from the DOH asking you to participate in an interview, you should contact us immediately.

Once we have reviewed your documentation, an experienced medico-legal adviser will take you through your practice profile, discuss the concerns raised, go through each of the relevant item descriptors, and generally assist you to prepare for your interview. After the interview, the DOH medical adviser may recommend no further action, a six-month review period, or a referral to Professional Services Review (PSR).2

Some of the more common criticisms we see from the DOH include poor documentation, and billing for services which are not clinically relevant. One of the most significant failures is not understanding the item descriptor, or believing that “near enough is good enough.” 

We hear a lot of reasons, which simply don’t cut it with Medicare – I work 90 hours a week; the practice does all my billing; no other item number fits the service; I didn’t know those items couldn’t be billed together; I have never read the MBS. And one to really avoid – but all my colleagues do it.


If the DOH makes contact with you, it doesn’t mean you are doing something wrong. It means you are a statistical outlier and you need to satisfy the DOH that your billing is appropriate.

MDA National provides a range of support to Members, from assisting with a simple self-audit through to full PSR Hearings. We are assisted in this process by external lawyers who are experts in this area. The sooner you contact us, the sooner we can put your mind at ease and start working towards a resolution.

Nerissa Ferrie
Medico-legal Adviser, MDA National

nerissa

References

  1. Department of Health. Practitioner Review Program. Available at: health.gov.au/internet/main/publishing.nsf/content/practitioner-review-program
  2. Professional Services Review. The Three Stages of Review. Available at: psr.gov.au/about-the-psr-scheme/the-three-stages-of-review
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