Medicare billing assurance template - Medicare Billing Assurance Toolkit

Contains examples of policy statements and operational guidance which can create a Medicare billing assurance approach in the practice.

Our practice is responsible for applying diligence, care and integrity when processing Medicare claims for services provided by our practitioners.

Our practice has developed this Medicare billing assurance manual to help us improve the efficient day-to-day running of our practice and meet our obligations. It contains important information about our values and responsibilities when billing under Medicare, and our system for reporting and addressing concerns about risks to accurate billing and instances of incorrect billing.

Values

Our practice adopts the Medicare billing assurance charter as part of our mission statement.

Communication

All health professionals in the practice will report compliance concerns to our designated Medicare billing assurance person (or group of people).

The contact details of the current designated Medicare billing assurance person (or group of people) are below [insert details of the current designated Medicare billing assurance person or group of people, and details of a backup person or group of people who should be contacted if the designated person is not available]

 

What our practice will do

Our practice will:

  • only submit Medicare claims for services that are medically necessary and clinically relevant to manage the patient’s condition, and maintain accurate records to substantiate services
  • meet MBS item number and legislative criteria for items billed and make sure the item numbers billed under the health practitioner’s name or provider number are approved by the rendering health practitioner
  • follow the practice’s Medicare billing assurance policy and procedures
  • report all Medicare billing concerns to the designated Medicare billing assurance person or group of people
  • undertake education and training on the MBS, our practice’s Medicare billing procedures and our billing assurance approach
  • make sure MBS billing data of health practitioners is regularly reviewed for accuracy
  • participate in checks, reviews and activities aimed at improving Medicare billing accuracy as directed by our designated Medicare billing assurance person or group of people, and
  • not engage in any behaviour aimed at discouraging or preventing Medicare billing assurance concerns from being reported, or taking adverse action against the health professional who reports Medicare billing assurance concerns

What our designated Medicare billing assurance person (or group of people) will do

Our Medicare billing assurance person or people will:

  • oversee, monitor and review our practice’s Medicare billing assurance approach
  • liaise with the department about Medicare billing questions and issues
  • make sure correct and current Medicare billing procedures are in place
  • provide a contact point for all health professionals to report Medicare billing assurance concerns
  • report on our practice’s Medicare billing accuracy, including risks and instances of non-compliance to senior management
  • conduct or oversee employee education on the MBS, Medicare billing procedures and our practice’s Medicare billing assurance approach
  • conduct or oversee periodic reviews of practice-level MBS billing reports
  • encourage practitioners to regularly review their MBS billing histories
  • conduct or oversee the investigation, evaluation, treatment and prevention of risks or potential cases of non-compliance, and
  • investigate any allegations of behaviour aimed at discouraging or preventing Medicare billing assurance concerns from being reported

Education and training

All practitioners and practice staff will undertake education and training on:

  • our practice’s Medicare billing assurance values and staff roles and responsibilities about correct billing under Medicare
  • the importance and operation of our practice’s Medicare billing assurance approach
  • how to use the MBS and requirements for MBS item numbers, and
  • our practice’s Medicare billing procedures

The designated Medicare billing assurance person will organise education and training and maintain records of completed training.

View the online Medicare education tools.

Process to address Medicare billing assurance concerns

All health professionals are encouraged to be proactive in identifying, managing and resolving Medicare billing assurance issues in accordance with our practice’s Medicare billing assurance approach.

If a health professional in the practice is aware of a Medicare billing assurance issue, in the first instance, the designated Medicare billing assurance person should be notified as soon as possible. If the health professional is concerned about maintaining anonymity, they may consider submitting an anonymous report (e.g. via mail or unmarked email) to the designated Medicare billing assurance person.

The designated Medicare billing assurance person may conduct or oversee an internal investigation, evaluation, treatment and future prevention of the Medicare billing assurance concern. We will make every effort to protect the identity of health professionals who want to report Medicare billing assurance concerns anonymously.

The designated Medicare billing assurance person will prepare a report for senior management.

Senior management considers each Medicare billing assurance issue to be a serious concern and commits to taking appropriate and timely action to manage each issue.

Protection for practitioners and practice staff who report Medicare billing assurance concerns

Our practice encourages and requires health professionals to report Medicare billing assurance concerns in a timely manner. We commit to investigating all concerns raised and to protecting health professionals from any behaviour aimed at:

  • discouraging them from reporting Medicare billing assurance concerns, or
  • retaliation against those who report Medicare billing assurance concerns

We will make every effort to protect the identity of health professionals who want to report Medicare billing assurance concerns anonymously. Where it is necessary to disclose information that will lead to the identification of the reporting employee, disclosure will be limited to persons who need to know.

No health professional is to:

  • engage in behaviour aimed at discouraging or preventing Medicare billing assurance concerns from being reported, or
  • take adverse action against practitioners or practice staff who report Medicare billing assurance concerns

Page last updated: 29 January 2016

This information was printed Monday 25 July 2016 from humanservices.gov.au/health-professionals/enablers/medicare-billing-assurance-template-medicare-billing-assurance-toolkit It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.