Surviving the inevitable Medicare audit: real life lessons

MEDICARE claims are increasingly scrutinised. Medical services and benefits accounted for $33.7 billion in 2019–2020 and growth in Medicare expenses is a major factor. Having been through the process myself, I’d like to pass on a few lessons learnt.

In 2018, the federal government announced an expansion of current auditing activities, including $9.5 million to be spent over 5 years to improve Medicare compliance and for debt recovery. In general, providers are financially responsible for making sure there are no incorrect claims, regardless of who may arrange their billing and paperwork. In cases of non-compliance, the provider is responsible to repay 100% of the rebate, even if they are employed on a salary or revenue-sharing basis. In 2019, the Shared Debt Recovery Scheme was introduced to cover medical practitioners who work in corporate medical services to provide a mechanism of sharing the potential debt between the parties.

In this article I describe the key lessons from a dietetic practice that underwent a successful Medicare compliance audit.

Dietitians are the third most commonly consulted allied health profession in the Medicare Australia Chronic Disease Management program. Healthier You, a private dietetic practice in New South Wales, was formed in 2008. To ensure providers understood and met the requirements of Medicare compliance, the practice developed an in-house training package. All staff (including administrative staff) were trained on Medicare requirements, and individual roles and responsibilities. Procedure documents were developed on the process of patient flow, data management and storage, documentation requirements, and generation and distribution of reports. The practice routinely used bioimpedance assessment machines (BIA) for anthropometry which provide time and dated stamped outputs, proof that the test and consultation took place on that particular day. An internal audit was performed on a random selection of documents to ensure compliance.

In 2016, Healthier You was contacted by the Health Compliance Branch of Medicare Australia to complete an Allied Health Services Audit. The practice was required to provide substantiating evidence of appropriate services for 122 clients who attended 422 consultations from January to December 2015. These clients were referred to the practice by 70 different doctors and Medicare benefits (items 10954 and 81320) were claimed by two dietitians.

The practice was required to provide evidence that:

• services were provided by the dietitian personally;
• there was a valid (signed and dated) referral form;
• there was an initial report for all clients and a final report for those completing all allocated services; and
• there were records (eg, clinical notes) to show services were provided on the dates claimed.

All documentation was requested to be provided in a 2-week time frame. Consequences for non-compliance were spelled out in the request.

The practice provided all of the requested data (approximately 1000 pages) and received notification one month later that, based on the evidence provided, there were no areas of concern and the matter was finalised.

Below are the four key learnings from this audit:

1. Understand, then play by the rules: The requirements for providing Medicare-subsidised services are well documented and described by others. It is the responsibility of the claimant to ensure that they understand and meet all requirements. Claiming the rebates with the wrong date of service or with a referral form that is not signed and dated by the provider are deemed Medicare fraud. It is the responsibility of the provider to ensure all Medicare requirements are met, regardless of who processes the claim.
2. Keep appropriate records: An electronic copy of any documentation should be made. These should be easily accessible and routinely backed up. Hard copies must be kept for 2 years after the date of service. Thorough and detailed clinical notes should be kept. Document all services provided and provide supportive evidence for all claims. Ensure that a report is generated after every initial consultation and for those completing all allocated visits.
3. Standardise the processes: Develop and document a standardised process to receiving, scanning, collating, retrieving and backing up all documents. Standardise an approach for developing initial reports for every new client and a final report for those completing all allocated visits. Assign and document a roles and responsibilities document for each person in the practice. Develop a checklist to ensure all tasks are completed. Complete an internal annual audit of the practice on a random selection of clients to assess your preparedness for auditing.
4. Use appropriate technology: Most practice management software enables automation of reports, and tools such as BIAs provide time- and date-stamped assessments. These technologies provide irrefutable proof of client attendance. Establish a process for backing up data and storage at an external location.

Although these lessons are from an allied health professional perspective, the learnings are relevant to all providers claiming Medicare benefits.

Peter Clark founded and is the Principal Dietitian at Healthier You in Port Macquarie (www.healthieryou.com.au). He is also completing his PhD with Griffith University looking at outcomes in private practice dietetics.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.