A case study involving an optometrist who repaid $80,000 to Medicare illustrates some common errors that can catch practitioners out. RUANNE BRELL offers her top tips to manage Medicare billings and avoid compliance issues.
Case study
The optometrist was referred to the Professional Services Review (PSR) when Medicare records indicated an unusually high volume of daily services, including more than 30 services on more than 20 occasions.
The PSR remained concerned the optometrist had not always met the Medicare Benefits Schedule (MBS) item requirements for the services billed. They considered the optometrist’s medical records were inadequate, that not all services were clinically indicated, and clinical management was not always appropriate.
The optometrist was reprimanded and agreed to repay $80,000.
Tip 1. Understand the item number
As a provider, you are responsible for claims to Medicare made under your provider number. Be sure you are applying the correct MBS item numbers and that your consultation covers the elements required for you to charge that item number.
Descriptions can be nuanced so ensure you check the full item descriptor, understand the requirements and check for updates.
For example, optometrists have been reprimanded over the use of MBS items that require patients to have been previously seen at the same practice as the providing optometrist. The PSR has determined this means the patient must be seen at the same physical practice, not at another practice within a corporate group.
Check with the government email advice service AskMBS if you are unsure about how to use an item number.
Tip 2. Keep careful records
When you make a Medicare claim for a service, you must maintain an adequate and contemporaneous record that demonstrates the service was provided.
As in this case study, inadequate documentation can result in an audit finding the benefit for those services should not have been paid. The government will seek repayment of the full amount of the Medicare benefits paid for the service.
Your records need to identify the patient and include a separate entry for each attendance by the patient for a service. Be sure to record enough details that explain why the service was needed, the clinical input you provided, and why the particular item number was billed.
Make sure your notes cover the:
• Reason for presentation and patient history
• Examinations or investigations
• Diagnosis (provisional or final)
• Management plan
• Time spent – if the item number has a minimum time component, make sure you record the time spent in the consultation. It is not enough just to select the item number for that consultation length.
Tip 3. Check all billings made under your provider number
You will be accountable for all services billed under your provider number and you are expected to make the decision about which item numbers to claim.
If administrative staff submit claims for you, make sure the process allows you to check and approve any claims billed under your number. If you are concerned your provider number may have been used to make incorrect claims, contact your professional indemnity insurer.
Claims can be audited after you have left your current practice, so keep a copy of all reports of claims submitted under your number in case any are ever questioned.
Tip 4. Keep up to date with peers and ask for feedback
Services billed must be clinically relevant. This is determined by what is acceptable to your peers, so it is important to keep in touch with peers and ensure your practice is in line with commonly accepted standards. You can ask practice staff to let you know if they think you have made a mistake.
Medicare reviews check for statistical outliers and anomalies. Being aware of your peers’ practices can help ensure your Medicare billing is consistent, or that you are aware of and can explain any differences. However, it is not a substitute for your own knowledge so always check the item numbers yourself.
Tip 5. Take special care to record referrals
Items 104 and 110 have been a recent focus of PSR reviews involving multiple specialities.
Concerns raised in relation to these item numbers included poor record-keeping as well as a lack of evidence of a referral requesting a specialist consultation, inadequate communication of outcomes to the referring practitioner, and co-billing a consultation with a procedural service when the record did not support that a separate consultation was performed.
Conclusion
The prospect of a Medicare audit can be daunting for practitioners. However, by following some principles of good practice, you will be better placed to avoid scrutiny of your billings or address any concerns.
Disclaimer: This article is intended to provide commentary and general information. It does not constitute legal or employment advice. You should seek legal or other professional advice before relying on any content, and practise proper employment decision making with regard to the individual circumstances.
FURTHER REFERENCES
1. Department of Health: AskMBS Email Advice Service
2. Avant resources: Medicare: what you need to know
ABOUT THE AUTHOR: Ruanne Brell BA LBB (Hons) is a senior legal advisor in the Advocacy, Education and Research team at Avant with almost 20 years’ experience in health and medical law.
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