Doctor Joe entered into a service agreement with a practice company whereby 40% of his billings were retained by that entity for nursing, administration and other support services.

He contacted MIGA soon after he received a letter from the Provider Benefits Integrity Division of Department of Health advising Dr Joe his billings had been the subject of a Medicare audit. The Department’s analysis raised a number of concerns in relation to Dr Joe’s billing practices, in particular:

  • The level of billing rendered for various items were far in excess of most of his peers (> 95th centile), and that his peers may not consider the level of services rendered or initiated to be clinically appropriate
  • Whether all MBS item requirements were met for every service.

The letter from the Department contained a spreadsheet of over 25 pages detailing two years of benefits paid that were the subject of the audit.

Doctor Joe was invited to attend a formal interview within 2 weeks to discuss the audit and the Medicare claims he had made. He was also invited to make voluntary acknowledgement and repayment of any services identified as incorrectly claimed, whether they be the subject of the audit or outside the audit.

MIGA’s claims team advised Dr Joe, in preparing for the interview, to review all the MBS item requirements and the patient health records that were the subject of the audit to ensure that they documented adequately that the MBS item requirements were met.

Doctor Joe spent many hours doing this task within the short time frame provided. It became apparent that for a considerable number of billings there were issues including:

  • The health record was poorly documented and could not substantiate the service provided and/or the duration of the consultation
  • Incorrect MBS item numbers had been used either by him or practice staff
  • Claims had been made by the practice staff using his provider number in relation to services provided by others, such as visiting locums and trainees who had not yet received a provider number
  • Incidents where services provided to one patient on the same day were claimed over subsequent days to obtain greater benefit.

Doctor Joe attended the interview and voluntary acknowledgements were made in relation to incorrect billings.

The Department was still not satisfied in relation to certain billing practices and referred the matter to the Delegate of the Chief Executive Medicare for referral to the Professional Services Review (PSR).

The doctor was then subjected to interviews by the Director of the PSR and subsequently a hearing before a PSR panel which lasted for a number of days.

The end result for Dr Joe was:

  • He was considered responsible for all billings claimed under his provider number notwithstanding that 40% of the billings went to the practice entity and its staff had been part of the incorrect billing practices¹
  • Repayments he was required to make in relation to incorrect or inappropriate billings were in the hundreds of thousands of dollars
  • His ability to claim certain MBS item numbers was suspended for a period of time
  • The practice entity terminated his service agreement on the basis of a significant breach of contract in failing to keep proper health records that comprehensively documented the service provided to each patient.

How does a doctor find themselves in this situation? What is Medicare’s investigative process and what does it mean for me? Surely the employer is partly to blame and held accountable by Medicare?

Find out all this and more at MIGA’s new claims hypothetical ‘Medicare – Does your Dawg bite?’ We will explore these issues and many more in an interactive, entertaining and enlightening session. See further information in this Bulletin. You literally can’t afford to miss this one!

¹ Legislation has introduced a Shared Debt Recovery Scheme operative from 1 July 2019

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