How to Prepare for a Medicare Audit

What is a Medicare Audit?

According to the Australian Department of Health, Health provider compliance audits and reviews are conducted in accordance with Australian legislation to protect the use of public funds and ensure that all benefits are correctly paid.

In the case of Medicare specifically, it refers to the Health Insurance Act 1973 which applies to all health providers claiming Medicare benefits.

An audit is an evidence-based assessment of a GP’s compliance with relevant requirements in relation to the payment of a benefit. Once complete, a review of the facts is undertaken and a decision is made.

Heavy penalties can apply if a GP or Clinic is found to be in breach.

These penalties are designed to encourage voluntary compliance with the legislative requirements for the payment of Medicare benefits.

Who may get chosen for a Medicare Audit?

In general, if you’re on the 99th percentile for any Medicare item, you may potentially expect to receive a call.

Obviously, every case is different and the decision is up to The Australian Department of Health. However, it’s important to be compliant and prepared regardless.

How should you prepare for a Medicare Audit?

So what can you do to ensure a good outcome?

Here are 5 important considerations for GPs when it comes to Medicare.

1. Read and understand the Medicare item descriptors

This is of paramount importance.

These Medicare descriptors represent written laws. As such, the wording has a very specific meaning and must be respected. Take the time to review these Medicare item descriptors so you understand what services apply and don’t apply.

For example, if you’re billing a team care arrangement (Item 723), the descriptor says that you must liaise with two allied health providers and receive written feedback from them as well as other requirements. Not undertaking these steps can lead to non-compliance which will be picked up during an audit.

When it comes to compliance, not knowing the rules is not a defence.

If you’re unsure, it’s best to get advice from an experienced colleague or GP network.

2. Start with the patient

Understand that the item numbers are there first and foremost to support patient care.

So, decide what the patient needs and then use the item numbers to support their treatment. Don’t start with the item numbers and ask yourself how many patients you can bill with this number.

3. Understand the process

Any initial approach from Medicare for an audit is purely mathematical.

In other words, you may be contacted if your usage differs substantially from the norm. So, don’t take it personally.

There actually may be good reasons for this. For example, you may have a large number of aged patients and therefore your use of the health assessment item numbers is high.

If you are in this kind of situation, then be in a position to explain this with facts and figures, and be able to show that your diagnosed rate of chronic disease has increased as a result.

This leads to the next point.

4. Know your demographic

If you know your patients and understand their rates of chronic disease, this will assist greatly.

The average full-time GP will have about 60 patients with Type 2 diabetes. If you have a particular interest in this area, then you may have many more than this, and this could explain your increased rate of care planning under Medicare.

If you’re able to document and explain these factors, then you will be able to demonstrate that you’re endeavouring to act in the interests of your patients, should you get audited.

5. Always maintain excellent documentation

If you receive an inquiry from Medicare and your response (as outlined in point four) is found to be inadequate, you will be referred to the PSR (Professional Services Review).

From there, you will be asked to provide your recorded notes supporting the billing of certain Medicare item numbers. If this occurs, make sure you have read Point 1 above.

In general terms, all notes must:

• reference the Medicare item descriptor
• indicate the clinical need
• demonstrate clinical input from the GP
• outline appropriate management
• exhibit comprehensive documentation and avoid inappropriate co-billing.

Any usage of Medicare can be found to be in breach across any of these five domains – so ensure you’re undertaking all five.

But don’t forget…

The Medicare item numbers are there to be used!

Don’t shy away from the Medicare system due to a fear of a Medicare Audit. If you follow the 5 tips above, you will be taking all the right precautions to ensure that your Practice is compliant.

We at Partnered Health Medical Centres seek to partner with and support our community of Doctors to serve Australian patients well, and encourage good rewards for good work.

Do you feel confident with Medicare items?

A corporate medical centre network like Partnered Health Medical Centres can help you.

We employ software and compliance systems to ensure all of the Medical records are transparent, well-kept and compliant.

Partnered Health also has GP Medical Professionals and Medical Directors who are well-versed in Medicare’s use – this means that you always have access to reliable resources whenever you need them.

That way, if a Medicare Audit occurs, the Partnered Health Medical Centres team are right behind you to ensure that the process is streamlined and stress-free.