March 2015 Contributing to the Integrity of the System Medicare Compliance Presented by Barry Sandison, Deputy Secretary, Health, Compliance and Information
Page 2 Department of Human Services • Manage nearly $150 billion pa in government health and welfare outlays. • Have 23+ million Medicare and around 7 million Centrelink customers. • Administer 932 million transactions pa. • House over 80 terabytes of data. • Data holdings increasing 30% pa.
Page 3 DHS Health Servicing • Five key responsibilities: – MBS/PBS registrations and entitlements – MBS/PBS claims and payments – Health compliance – Other health programmes – Health Budget Initiatives
Page 4 Our Health Compliance Model an c Le v el of isk Detect and review f. R m pli Prosecute lo ve Co High Le e. C os ts High Low Compliance Strategies
Page 5 Risk Treatments LOW RISK - Help and Educate - Remind and Alert - targeted feedback letters MEDIUM RISK – Detect and Review - General audits - desk and site HIGH RISK- Prosecute - Criminal Investigations
Page 6 The move to online Over 360 million services generated through about 39, 000 health practices in 2013 -14, approx. : • 12, 000 (31%) lodged 100% digital • 18, 000 (46%) lodged some digital • 9000 (23%) lodged nil electronically, (however, they generate only about 3. 8 million services - around 35 services each per month).
Page 7 Its all about the data
Page 8 2014 - Claiming for MBS Services and Benefits Benefit Services Professional Attendances $ 9, 038, 404, 921 170, 800, 157 Therapeutic Procedures $ 3, 286, 199, 746 22, 732, 845 Diagnostic Imaging Services $ 3, 056, 663, 948 23, 480, 345 Pathology Services $ 2, 541, 744, 288 127, 397, 445 Miscellaneous Services $ 1, 323, 291, 479 11, 126, 775 Diagnostic Procedures and Investigations $ 472, 460, 822 6, 514, 133 Dentist, Dental Specialist and Dental Prosthetists & $ Dental Benefits Schedule 288, 401, 720 4, 474, 445 Oral and Maxillofacial Services (by Approved Dental Practitioners) $ 11, 647, 679 102, 049 Cleft Lip and Cleft Palate $ 1, 936, 493 8, 183 Total $ 20, 020, 751, 096 366, 636, 377
Indicators: Potential Anomalous Claiming Patterns Page 9
Page 10 Indicators: Outside Scope of Practice • Odd one out rendering services unusual for that specialty – Top 100 data – High servicing – Low servicing
Page 11 Indicators: Inadequate clinical input • Too many hours in a day • Too many patients in a day • Too many investigations • Too many procedures
Page 12 Update - Key Recent Enhancements • Enhanced Risk Identification and Prioritisation – Moving from process to task activities. – Key risk topics for 2014 -15, include Pathology, Diagnostic Imaging, Specialists, General Practitioners, Public Fraud. • Outcomes Monitoring Framework – Demonstrable increase in performance: total debts and behavioural change.
Page 13 Challenges • Growth of System: range of disparate analytical and information systems. • Rules based system: risk selection, prioritisation and quantification. • Complexity of system: efficiency and volume of compliance audit operations. • Organisational design: moving to continuous improvement - process to targeted based activities.
Page 14 Where Next? • • • Industry sharing best practice. Trials External validation of processes and tools. Greater exploitation of data holdings. Greater data sharing. Exploration alternative treatment strategies.
Page 15 Collaboration Dissemination of intelligence. Dissemination of best practice. Increased engagement/consultation.
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