Medicare Monitoring
Sophisticated methods can detect possible inappropriate practice or incorrect claiming.
Some examples of these include:
- identification of unusual patterns of item combination or usage
- using computer algorithms to monitor and compare the claiming profiles of health professionals to identify inconsistencies
- identifying and applying patterns learned from previous cases of non-compliance
- investigating tip offs
Do not underestimate these resources available and methods used
Key messages
- Whenever your provider number is used - you are responsible
- If your provider number is used incorrectly, you are still personally responsible and liable
- Ensure awareness and approval of how your practice or hospital use your provider number
In all cases, items or services claimed to Medicare MUST:
- not be an excluded service
- have been medically necessary
- show evidence in the notes of sufficient medical input
- demonstrate notes that are contemporaneous and adequate
- show evidence of notes and demonstrate that the conditions of the item number were met
Be careful and mindful about:
- over-servicing (eg the 80/20 rule - you may have practised inappropriately if rendered 80 or more professional attendances on each of 20 or more days in a 12-month period)
- incorrect billing (wrong item number, descriptor not met, no Medicare benefit)
- inadequate history
- failure to address the medical problem
- treatment unacceptable to your peers