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News Bulletin : ADA News Bulletin December 2011
13 DECEMBER 20 11 THE INCREASED MEDICARE COMPLIANCE AUDITS INITIATIVE The Increased Medicare Compliance Audits (IMCA) Initiative details were published in the May 2011 issue of the News Bulletin. However, it is again worth noting that with the introduction of this initiative, additional powers and penalties have been introduced. The Health Insurance Amendment (Compliance) Act 2011 took effect on 9 April 2011. It applies to Medicare services provided on or after this date. THE LEGISLATION • Allows the Chief Executive Medicare (CEM) in the Department of Human Services (DHS) to give a notice requiring a person to produce documents to substantiate a Medicare benefit paid in respect of a service; • Provides for an additional financial penalty for certain practitioners who are not able to substantiate a Medicare benefit paid in respect of a service; and • Provides an opportunity for a health professional to seek a review of a decision on amounts recoverable. CONDITIONS PRIOR TO ISSUING A NOTICE Before a notice to produce documents can be issued, the CEM must fulfil several conditions: • Firstly, the CEM must have a reasonable concern that the Medicare benefit paid for a service may exceed the amount that should have been paid; • Secondly, the CEM must take advice from a DHS medical adviser on the kinds of documents that contain information relevant to substantiating the Medicare benefit; • Thirdly, the CEM must take reasonable steps to consult with a relevant professional body about the types of documents that contain information relevant to substantiating a Medicare benefit before commencing a compliance audit; and • Finally, the CEM must first give the person a reasonable opportunity to respond to a written request to voluntarily provide documents. PRACTICAL IMPLICATIONS OF THE REFORM The practical implications of the reform are that: • The Department of Human Services can now issue a notice to health professionals, or a person in charge of the professional's records, if there is a reasonable concern that a Medicare benefit has been paid that exceeds the amount that should have been paid. This notice will require a health professional to produce documents to substantiate services. • An administrative penalty with a base rate of 20% for unsubstantiated amounts that total more than $2,500 has been introduced. This penalty is automatically decreased where a health professional voluntarily cooperates with an audit, but can be increased where a health professional does not cooperate. Health professionals can seek a review of a decision from the Department of Human Services to recover funds where a Medicare service has not been substantiated. PENALTIES If a practitioner tells Medicare Australia that an incorrect amount has been paid for a service: • prior to being contacted by the CEM, the penalty is reduced by 100% (no penalty); • before a notice to produce documents is issued, the penalty is reduced by 50%; • after a notice to produce documents has been issued but before completion of the audit, the penalty is reduced by 25%. On the other hand, if a practitioner: • does not respond to a notice, the full amount of the services identified in the notice become repayable and the penalty is increased by 25%; or • has been unable to substantiate an amount paid for other services in the previous 24 months, and the total they repaid was more than $30,000, the penalty for the current amount is increased by 50%. The message is clear and the advice to members is that if there have been errors made then the earlier this information is conveyed to Medicare Australia the better; a penalty may be avoided or at least minimised. The ADA hopes to have an interview with a senior Medicare Australia officer available shortly. This will be placed as a podcast on the website and will be included in the February edition of the ADA's Dental Files. Robert Boyd-Boland Chief Executive Officer For more information it is recommended that members visit and read carefully the information at: www.medicareaustralia.gov.au/provider/business/audits/imca-resources.jsp This site provides a detailed Fact Sheet; Medicare compliance audit flow chart; FAQs and some useful forms. The Health Insurance Amendment (Compliance) Act 2011 can be found at: www.comlaw.gov.au/Details/C2011A00010 "The message is clear and the advice to members is that if there have been errors made then the earlier this information is conveyed to Medicare Australia the better..."
ADA News Bulletin November 2011
ADA News Bulletin February 2012