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Many GPs who undergo a Medicare Australia audit have legitimate reasons for their practice differences. By Heather Ferguson THIS financial year at least 400 health practitioners, many of them GPs, can expect to receive a phone call or letter that leads to fear and panic.
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That contact will come from Medicare Australia, advising the GP that their Medicare or PBS claiming is outside the norm. Some of these GPs will be reviewed under the Practitioner Review Program (PRP). The review will determine whether they have been involved in inappropriate practice, as deemed by their peers. But the good news is, in many cases, the situation is not as terrifying as it seems.
Initial contact by Medicare Australia doesn’t mean the Federal Government body believes a GP has done something wrong. Clinical > Patient > Organisations > Government > Careers
MrColinBridge, national manager for Medicare Australia’s program review division, says Medicare and PBS data do not pick up legitimate differences between GPs. “Practitioners are very much pursuing [different interests] such as natural medicine that you can’t see through the data,” he says. Therefore, the first role of the Medicare Australia-appointed medical adviser is to contact the doctor to ask why their practice statistics are different to their peers. If the adviser is satisfied with the GP’s explanation, the matter ends there. While 526 practitioners were identified through Medicare Australia statistics as possibly being involved in inappropriate practice in 2006-07, there were only 308 PRP reviews. Some 324 reviews — including those remaining from previous years — were closed after the doctors addressed Medicare Australia’s concerns. Just 26 doctors were referred to the Professional Services Review (PSR) to be judged by a committee of their peers. The most common causes of inappropriate practice investigated by Medicare Australia are ‘upcoding’— where a Medicare item of a higher value than is indicated is used — and over-servicing. The latter usually relates to matters such as inappropriate use of pathology testing. These days, it’s uncommon for GPs to come to Medicare Australia’s attention for breaching the 80:20 rule (seeing 80 or more patients on 20 days or more in a year). “The 80:20 rule is reasonably established and understood,” Mr Bridge says. However, GPs can still be reviewed if they see a high number of patients each day or year, even if they fall below the threshold of seeing 80 patients a day. An allegation of inappropriate practice can be upheld if there are concerns the GP hasn’t spent enough time with the patients to provide proper care. If GPs are unable to satisfy the medical adviser that they have not been involved in inappropriate practice there are still some steps involved before the GP is sent to the PSR. Doctors are usually provided with time to reflect on why their statistics are different to the norm. “In a way it’s a self-audit,” Mr Bridge says. “What we find is the vast majority of practitioners go through the process and say ‘actually I am going to change, I accept what I am doing [is outside] what the general group is doing’.” If the GPs’ future Medicare or PBS data supports that they have made changes to their practice, that’s the end of the matter. Whether they will be asked to repay Medicare depends on the circumstances involved. If GPs have been reckless, or the items that have been misused are of a high value, they may be asked to repay Medicare for the services.
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“[But] if it is a genuine misunderstanding, as a broad approach, we would not necessarily seek to get money back,” Mr Bridge says. Of course, while this sounds reasonable, the reality is GPs contacted by Medicare often describe feeling humiliated, embarrassed and intimidated by the medical advisor. But GPs don’t need to face Medicare Australia alone. Ms Fiona Davies, AMA NSW director of workplace relations, says AMA state branches can assign someone to accompany the GP in meetings with the medical adviser. “It’s a terrifying experience and I can’t really think of anything worse,” she says. Ms Davies says most GPs contacted by Medicare Australia who approach the AMA for help are “at the top of the bell curve” for level C consultations or pathology referrals. But often there is a simple reason that can be explained at the time of first contact with the Medicare Australia medical adviser. “The vast majority of these discussions resolve themselves fairly quickly,” she says. “For instance, the doctor might [refer for] an enormous amount of pathology but they practise in Kings Cross and have an interest in sexual health. “The medical assessor often says they knew exactly what type of practice it was from the statistics, they just need to confirm it.” Unusual items, such as for after-hours — the subject of a Medicare Australia audit this year — and skin cancer, can also bring GPs to the attention of Medicare Australia, Ms Davies says. In one case, a GP lived above his surgery and patients frequently took advantage of this to seek his help out of hours for routine matters. The GP claimed the after-hours emergency item when a standard consultation was being indicated. Ms Davies, along with the PSR, Medicare Australia and medical defence organisations, point to one common failing among doctors who are unable to defend claims of inappropriate practice: poor medical records. While Medicare Australia doesn’t have the power to compel doctors to provide clinical records, reviewing the records with the advisor can help resolve issues of concern. “Doctors have patients’ rights to consider [but], particularly when you get into unusual circumstances, making records available, even if they are deidentified, may bring the matter to a conclusion very quickly,” Mr Bridge says. Medical records become even more important if the doctor is referred to a PSR committee, which has the authority to demand access to records. GPs have little hope of proving their use of Medicare items has been appropriate or that they have provided appropriate and necessary care to patients if the records are lacking. And there’s a high price to pay. GPs referred to the PSR face the prospect of a reprimand, being asked to repay Medicare and/or partial or full disqualification from Medicare and the PBS. The PSR now must also refer any concerns about patient care to the doctor’s state medical board and other bodies such as Australian General Practice Accreditation Limited. Dr Paul Nisselle, general manager and clinical risk manager for the Avant Mutual Group, says many GPs who have fallen foul of the Medicare system have been unable to demonstrate, from their notes, the clinical content of every consultation that is subject to review. Therefore, they have been unable to demonstrate that each service was necessary for the clinical care of the patient. “I’ve seen entries which read ‘URTI – Pen’,” Dr Nisselle says. “Now that presumably means that the patient presented with an upper respiratory infection for which penicillin was prescribed, but no history is recorded, no exam findings are recorded [or] details of exactly what was prescribed.” The PSR agrees that medical records are a major problem. “The most obvious concerns that we have at the moment is the standard of clinical note-taking,” says Mr Peter Skeen, PSR business development manager. “Our legislation requires that adequate, contemporaneous notes be taken. “In some circumstances the notes would make it difficult for other practitioners to take over the care [of the patient]. “A lot of doctors say I know the patient, I know what I meant, but fail to see that they might be hit by a bus tomorrow and someone else will have to see the patient.” On the other hand, good records can save a GP from the angst of a PSR committee hearing.
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Before a committee hearing, PSR director Dr Tony Webber reviews the case and is increasingly meeting with doctors. “Quite often we will see practitioners whose notes are more than adequate … and the clinical input justifies the item,” Mr Skeen says. “What usually happens is these practitioners will be identified in the director’s part of the process and he will dismiss [the referral].” But avoiding a Medicare Australia or PR review is, of course, a much better option. Mr David Dahm, CEO of practice management company Health & Life, says GPs could also avoid trouble if they paid better attention to the regular updates on their Medicare and PBS claims provided by Medicare Australia. “A lot of doctors throw it in the bin or don’t look at it,”he says. But the Medicare and PBS statistics provide GPs with an opportunity to audit their own records. If any problems are identified they can correct them, Mr Dahm says. Then, if Medicare Australia does come calling, the GP will also be able to show that they have already taken steps to address any concerns raised. Mr Dahm says given the increasing number and complexity of Medicare items, errors are more increasingly likely to occur. He advises GPs to work out what items they are likely to use, research how to use them appropriately and put systems in place to ensure they are used properly. The practice manager and staff should be involved in this process. “As long as you are doing the right thing, and I think most doctors are, you don’t have much to fear,”he says. WHAT HAPPENS WHEN A GP IS REFERRED TO THE PSR? If the PSR director agrees the GP has a case to answer, there are two possible outcomes. The GP and the director agree on penalties or sanctions; otherwise the GP is referred to a formal hearing before a PSR committee made up of their peers. A GP can appeal against the appointment of a particular committee member if they are concerned about bias. If the finding of inappropriate practice is upheld, the draft decision is sent to the PSR determining authority. The GP has an opportunity to make submissions to the determining authority before a final decision is made. GPs have the right to appeal to the Federal Court if they disagree with the final decision. WHAT CATCHES MEDICARE ’ S ATTENTION? In general: * The number of services provided in a year. * Daily servicing levels. * The level of services provided to the same family members. * Pathology referrals. * Volume of PBS prescribing. Common concerns with Medicare items include: * Upcoding of professional attendance items such as claiming a standard consultation (items 23 or 53) when a short consult (items 3 or 52) would be more appropriate. * Claims for a long or prolonged consultation (items 36 or 44, 54 or 57) when a standard consultation (item 23) would be more appropriate. * Claims for suturing a deep wound when a superficial wound was repaired. * Including the time for a procedural item, which has its own specific item number, as part of the time taken for the associated consultation. * Claims for excision of a large skin lesion when a small lesion was excised. * Claims for a more expensive item that requires a specimen to be sent for histopathology, but failing to send the specimen for testing. KNOWING YOUR Bs, Cs AND Ds ONE of the areas of confusion for some GPs is when to charge a level C or D. A common mistake is to base the decision on the length of the consultation. However, according to the level C item descriptor, the consultation must also involve a detailed history, examination of multiple systems and a management plan for one or more problems. "From our experience what occurs is the consultation lasts at least 20 minutes so the practitioner says 'that must be a C'," says Mr Peter Skeen, the PSR's business development manager. "If there is no detailed history and it's just a matter of talking to the patient for 20 minutes then a level C is not appropriate." Equally, if the consultation does meet the complexity criteria for a level C item,
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but finishes before 20 minutes, GPs should claim the level B item. AVOIDING STAFF FRAUD EVEN when GPs do the right thing they can find themselves embroiled in a Medicare review or investigation. Last year, a receptionist at a Queensland medical centre was investigated after it was alleged they created false cash claim documents to obtain Medicare benefits for themselves and several others. The receptionist received a suspended sentence and eight others received good behaviour bonds or community service. Mr David Dahm says situations like this are likely to become more common in the future as life becomes more expensive. "People want a nice house and car. What you want to do is remove the temptation in the practice for these sorts of things to occur," he says. Among the strategies Mr Dahm recommends is for GPs to initiate billing from their consultation room. "All the receptionist does is print out the receipt and take the money," he says. Mr Dahm also advises against giving one staff member responsibility for both the billing and banking. For example, if the patient paid a gap payment of $20, the receptionist could put the money in their pocket and change the bill to 'Medicare benefits only', he says. But while staff will be held accountable for any fraud they commit, GPs shouldn't expect to be get away with offloading responsibility onto them for misuse of Medicare items, says Mr Colin Bridge, national manager for Medicare Australia's program review division. "If there is mis-itemisation or incorrect claiming it is still the responsibility of the provider," he says.
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