Specialists are now firmly in the sights of the Medicare compliance watchdog, with inappropriate billing for specialist treatment and management plan items now in the top ten of the Professional Services Review’s most frequent audits.

In its 2019-20 annual report, the PSR has highlighted a range of compliance concerns relating to MBS items 132 and 133, saying its reviews this year have targeted specialties including cardiology, rheumatology and neurology.

Concerns about specialist claims raised by PSR director Professor Julie Quinlivan related to:

• Cases where there was no record of an attendance on the date of service;
• Patients not meeting eligibility requirements;
• Required elements meant to be included in plans not being present;
• Minimum time requirements not being met;
• The treatment and management plans of ‘significant complexity’ being: “letters back to referring practitioners as typically seen for MBS Item 110 and 116 services or else a short hand written paragraph in an inpatient patient record or a template”.

The PSR director also raised concerns around potential double dipping, warning that “paid public hospital time was spent seeing private patients, but the generated private income was not disclosed to the public hospital employer.”

“Some referred physicians repeatedly billed minimum time requirements totalling more than 15 hours a day for MBS Items 132 and 133, even before considering time required for their other billed items on the date of service, and their other daily commitments that sometimes included substantial public hospital roles,” the report found.

In its report the the PSR said it had dealt with 96 cases in the last year, from which it had clawed back $21 million in inappropriate billing from 88 negotiated agreements.

Conflicting advice

Financial advisers told the limbic that the PSR’s report showed a need for improved guidance and billing systems to allow practitioners to comply with MBS rules.

Medical Billing Experts Managing Director Loryn Einstein said the main driver behind non-compliance was a lack of clarity created by inconsistencies and contradictions in advice from three different official sources to practitioners around how to properly use MBS items.

“There’s the Medicare team and the Medicare software which is assessing whether or not to pay a claim, then there’s AskMBS which gives advice if a practitioner is not clear on what to do, and then there’s the Department of Health compliance area,” she told the limbic.

“All three work independently – there is some overlap but they, on many occasions, do give conflicting advice. There needs to be better coordination.”

This view was shared by Margaret Faux, founder and CEO of Synapse medical administration company, who said that while the PSR’s analysis may include genuinely concerning cases, the majority of non-compliant billing appeared to be related to system issues rather than deliberate abuse.

She echoed Ms Einstein’s calls for greater clarity from those enforcing MBS compliance, adding that as a result of the confusion, many doctors relied on advice and explanations from colleagues that often turned out to be inaccurate.

“That doesn’t excuse them because ignorance is no excuse of the law,” Ms Faux said.

“But that is a reality – a lot of specialists may mistakenly therefore believe that because the patient is complex, they can claim item 132 [if for example] the patient has a comorbidity.”

In the PSR report, Professor Quinlivan said the auditors had agreed to work with the Department of Health in future to provide further input into AskMBS.

Another key concern, Ms Einstein added, was that regardless of how careful doctors are when using items, they may still strike trouble if colleagues had failed to comply with MBS guidelines when billing treatments for the same patient.

“If we’re not doing the billing for those other doctors, we would not know that several others have gone to see this patient and billed inappropriate numbers that might end up throwing our clients into an audit situation that we’ve done our best to avoid,” she said.

Meanwhile, both advisers noted that the public and private case mix that doctors deal with day-to-day in hospitals may be compounded by confusion over private practice rights and the rules that they function within.

This often made it difficult to appropriately delineate the time spent between public patients and private patients being treated in public hospitals, adding further complexity to MBS compliance, Ms Einstein said.