What You Need to Know about Medicare Compliance

An overview of the FCR Faculty Forum from the 2021 ASM

At the recent Annual Scientific Meeting, the FCR Faculty Forum focused on what a radiologist needs to know about complying with Medicare. Presentations were provided from three different perspectives. The session was extremely informative and provided valuable insights for members. Here is an overview of the session for those who missed it.

Presenter One: Dr Lincoln Gillam

Dr Lincoln Gillam, Chair of the RANZCR Diagnostics Economics Committee (DEC), provided the College’s perspective and encouraged members to reflect on the structure of the radiologist/employer relationship and Medicare billing.

• The DEC is the College committee which provides advice to the Faculty of Clinical Radiology Council on economics and policy matters, particularly related to Medicare and government policy.

• The radiologist is solely responsible for the use of their provider number. It can be considered in the same light as a passport or citizenship.

• Radiologists have a responsibility to know what is being billed under their provider number. It is recommended that you check what is being billed by your employer under your provider number each month.

• A list of billings under your provider number can be requested from Medicare.

• Compliance activities are conducted against the holder of the provider number, the radiologist, not the radiology practice.

• It is important to review your employment contact carefully and consider if indemnity against repayment of funds to Medicare, if non-compliance is identified, is covered in the contract. It is worthwhile to have a legal review of any contract before signing.

• You can request that your employer does not use your provider number to bill particular services or particular item combinations.

Presenter Two: Mr Alex Taylor

Mr Alex Taylor, Director of Risk Treatment from the Benefit Integrity and Digital Health Division of the Federal Department of Health, provided insights into the government’s approach to Medicare Compliance.

The purpose of Medicare compliance activities is to protect the healthcare payment system to ensure sustainability of the health system. The Department of Health responds to non-compliance with a range of treatment approaches which are proportion to the level of concern around non-compliance. The treatment levels escalate as follows:

• Targeted letter campaign

• Audit

• Practice review program

• Professional service review

Priority areas for investigation this year include:

• Telehealth and COVID-19 items

• Practice incentive programs

• Potentially invalid referrals

• Patterns which may indicate opportunistic claiming that may not be clinically necessary. The Department of Health has recently published the Health Provider Compliance Strategy (1) which details the priorities for 2021−22. Department of Health resources to assist practitioners in understanding Medicare billing include:

• Ask MSB email advice services at AskMBS@health.gov.au

• MBS Online at www.mbs.gov.au

• PBS Online at www.pbs.gov.au

• Services Australia MBS information at www.medicareaust.com/index

• Doctorportal Medicare Billing eLearning Module www.doctorportal. com.au

Presenter Three: Ms Gae Nutall

Ms Gae Nutall, Risk Advisor at MDA National, provided advice on what your Medical Defence Organisation (MDO) can do for you.

• If you receive any kind of notification from Medicare, the first thing you should always do is contact your MDO.

• Even if your employer pays for your medical indemnity insurance, the policy is an insurance policy directly between the MDO and the individual radiologist. The employer has no involvement in this relationship.

• All MDOs work together with the Department of Health and are aware of compliance activities to support their policy holders when required.

• ‘My colleagues bill this way’ is not an acceptable defence, so it is important to have a clear understanding of the items you are billing.

• Ensure all referrals and services you provided can be justified as clinically appropriate.

• You can check all provider numbers registered under your name and delete those no longer used via the PRODA (2) website.

• Recommendation to visit the Department of Health resource on Provider Compliance Education. (3)

References

Department of Health. Health Provider Compliance Strategy. Available at www.health.gov.au/sites/default/files/documents/2021/09/health-provider-compliancestrategy-2021-22.pdf

Services Australia Provider Digital Access (PRODA) www.servicesaustralia.gov.au/organisations/business/services/proda-provider-digital-access

Department of Health. Health Provider Compliance Education. Available at www1.health.gov.au/internet/main/publishing.nsf/Content/For+Health+Professionals-1Volume 18 No 1 | December 2021 13