Medicare fires warning shot over ‘urgent’ items

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Medicare puts doctors on notice over suspiciously high use of urgent after-hours MBS items


Medicare has put doctors on notice that they will be scrutinised for suspiciously high use of urgent after-hours MBS items.

Personalised, targeted letters have been sent to individual doctors based on their claiming behaviour for urgent after-hours items 597 and 599 during the 18-month period ended in December 2015.

The letters, sent on 27 April, ask the doctors to review their claims and “voluntarily acknowledge” any incorrect billing.

“No letters were directed to a deputising service or individual GP clinics,” a Health Department spokeswoman said.

Concerns over the inappropriate use of urgent after-hours items had been raised in many forums nationally over the past few years, she said.

“This, together with the Medicare Benefits Schedule (MBS) data has indicated a sharp increase in the amount of urgent after-hours claims made, and an increase in the number of individual health professionals claiming these items.”

The spokeswoman clarified that the action was not part of any special Medicare or Professional Services review.

“To date, targeted letters have been the only form of compliance activity undertaken,” she said.

“The department selects cases for investigation/audit based on the identified risk, and evidence that an offence may have occurred.

“The department will look at data analytics and, on occasions, review providers with a high number of services comparative to their peers.”

She said an audit would follow only if there were strong evidence of non-compliance.

“As per legislation it is the sole responsibility of the individual health professional for any MBS claims made under their registered provider number.”

According to a letter from the Department of Human Services, sent to a doctor in late April, the definition of an urgent service is: “The requirement of the item descriptor is met if patient’s concerns about their condition are of such alarm to them, that most medical practitioners would respond to those urgently.”

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