Health Insurance Amendment (Compliance) Bill 2009 - Medical Professionals
The ‘Health Insurance Amendment (Compliance) Bill 2009’ is currently before the House of Representatives. This Bill is intended to give effect to the Increased MBS Compliance Audits (IMCA) initiative. The IMCA initiative was announced in the 2008-09 Budget. It aims to ensure the integrity of the Medicare scheme by:
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Increasing the number of compliance audits undertaken by Medicare Australia (increase from 500 to 2,500 per year);
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Compelling practitioners to produce evidence to verify their Medicare claiming when audited (e.g., evidence to confirm that the patient meets the conditions of claiming an item number); and
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Introducing administrative sanctions for Medicare practitioners who claim incorrectly (e.g., administrative penalties and MBS claims paid incorrectly to be repaid).
These changes are being made as in the last five years alone, Medicare expenditure has increase by 43% and there has been a considerable growth in both the number of items (23%) and the number of individual providers (15%). As part of ensuring the integrity of the system, a small percentage of providers will occasionally be asked to verify their claims.
Currently, providers are under no legal obligation to substantiate their MBS claims unless being investigated for fraud. This means that noncompliant providers can essentially choose not to be audited. The proposed legislative amendments to the HIA will provide that Medicare Australia can only issue an audit where there is reasonable concern that a MBS payment may not have been claimed correctly. There are four processes through which a provider’s claims may be identified for audit, they are:
1. A provider has used an item/s with a medium to high risk of non-compliance;
2. A provider’s claiming statistics appear to be unusual or irregular;
3. A provider’s claiming statistics are different to their peers; or
4. A provider has been identified through tip-offs.
In summary the legislative amendments to the HIA will give additional power to Medicare Australia to require practitioners to produce evidence to verify their Medicare claiming when audited by Medicare Australia and for the introduction of financial penalties for practitioners who make incorrect Medicare claims.
To ensure that you are complying with the requirements of the HIA, you will need to be confident that your internal systems support each Medicare Claim you lodge. Part of the requirements under the proposed legislation revolves around the need to produce documentary evidence of the service being provided. This means that all claims lodged will need to be appropriately supported. It should be noted that the Practitioner can choose not to release any patient information to the investigating officer. If this is the option taken, then Medicare will make a Medical Practitioner made available to verify the supporting evidence for claims made through access to the patient files.
If you would like us to review your systems and processes to ensure that you’re complying with the requirements of the proposed legislation, please do not hesitate to contact us.
To find out more information about IMCA initiative visit www.medicareaustralia.gov.au then go to For health professionals > Doing business with Medicare Australia Audits and Compliance > National Compliance Program or alternatively please contact our office.