Medicare Billing post PSR-Items 721/723 and SMART Goals

Written by: Dr. Anchita Karmakar

Over the past few years, as I navigated my way through law school and my journey as a clinician going through the Medicare/Professional Services Review audit, I have had the privilege of developing some personal beliefs regarding certain item numbers that are commonly billed in the world of General Practice. Although I cannot share the deliberations and findings made against me during this process without me going to jail for 12 months(as per the Health Insurance Act Section 106ZR) I can, however, share what I would do as a clinician post this experience. I highly recommend everybody going through this process once in a lifetime, as it is an invaluable lesson of life, where you realize almost everything you have ever done as a clinician was technically deemed incorrect. So without any further delay here are my 'pearls of practice' post PSR audit.

Don't mean to state the obvious but this is an article just written as an opinion piece and not intended as legal advice or advice regarding 'how to bill.' It is just my reflection and observation of what I would do based on experience. I am also not admitted as a legal practitioner yet so please do not think this is coming from a lawyer.

MINIMUM REQUIREMENTS ON TOP OF THE MEDICARE DEFINITION 

Most of you reading this article will be intelligent and capable of looking up the actual statute(statement of law) that defines what is needed as a clinician to bill an Item 721/723. It is a minimum requirement to have the capability to read these things and understand it if you are entitled to bill Medicare. Not withstanding the fact that as a medical graduate in Australia there are no formal teaching on how to bill these items, it is still the government's expectation you would know this automatically.

If in doubt here is the link:

https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=723&qt=ItemID

If you need further guidance on this basic level please feel free to contact me personally. Happy to go over the language over coffee. No need to pay and attend expensive seminars for this as between colleagues we can sort this out.

On top of the obvious which is written there here are my pearls:

-Bill TCA only after you have written/signed confirmation scanned and entered into your practice software of two clinicians whom you have consulted to create the TCA plan. The whole point of this is to illustrate the fact that during the time you took to create the TCA plan, you have made two phone calls or met with two allied health practitioners and or other Doctors, whom you discussed the matter with and they have acknowledged that this care is needed and that they are happy to participate in that care. The DATE in which you bill the TCA and the date that the scanned, signed confirmation of those TWO allied health practitioners must be the same for you to pass the test.

-Each GPMP/TCA produced must have a document that is tailored specifically to that individual patient. Eliminate any drop-down and or clickable things to prepopulate your plans as that may look like you are just copying the same plans. At the end of the creation, what you want is for your patient to walk away with a piece of the document created by you and the patient which has a clear individualized plan for their chronic disease management, which they can carry around and reproduce and review as needed. It is also essential to make sure that there is evidence that your patient has signed the plan(a copy of signed planned must be scanned in) and the patient got a copy given to them, BEFORE BILLING the items.

-The medical condition must be 'complex' requiring multidisciplinary care and not necessarily preventative as such. My token is if the 'condition' can be deemed to be a 'symptom' or a manifestation of an underlying chronic medical condition, that in itself, may not constitute a chronic complex medical issue, which may be deemed inappropriate for a care plan as such. Going forward, on my point of view, I will not be doing these plans for people that suffer from Hypertension, Hypercholesterolemia, Osteoporosis with no fractures, Obesity-unless evidence of metabolic disorder and or complications, Menopause, Osteoarthritis, and Depression/Anxiety. This does not mean if you have been billing these conditions you have been inappropriately billing, but this is just my take on what I will do going forward as a GP if I ever bill these items

-Although these items are not time-based I will ensure that my software is open for the actual duration it takes for me to do these cases as it can technically help your case if you ever get audited

-I will not ask my practice nurse to do my care plans as I feel it is too important of a task to delegate when it requires such an intricate level of details for it to be compliant. At the end of my day, I will also get a copy of all my days billing, make sure I retain a copy of my care plans created on my personal records and know what is billed under my name for these high ticket items. As part of my contractual agreement with my practice I will make sure the proprietor is aware of my action to retain these records in case of my audit, especially if in case I leave the practice.

-As an added assurance, I have produced a document in the form of a statutory declaration for my patients, and whenever a TCA and or a GPMP is billed the patient signs the stat dec, which is then scanned into my software illustrating that from the insured's point of view, I as the provider of care have full filled my obligations to bill Medicare for that item number.

You only have to not do ONE part of these points and point mentioned in the statute to be deemed you were billing inappropriately, so this is very important to understand.

WHAT ARE SMART GOALS?

Recently as the PSR vamped up the audits, the SMART goal term is recurrently being used. SMART goals stand for "Specific Measurable Attainable Relevant and Time-based" goals. This particular acronym is quite favorably used in the world of various professions but it seems like the recent PSR Director is in favor of this particular style of medical documentation and thus, this is currently recommended. Making sure this acronym is embedded into your individualized plans is certainly a good idea under the current condition.

ISSUES WE ARE FIGHTING AGAINST

In April, for three days, the Federal court will be hearing from various clinicians and experts regarding the alleged flaws in the current audit process. I am arguing that under the current process, even the most well trained, obedient, intellectual and ethical clinician would fail the PSR audits as nobody can anticipate what standards would be permissible-unless you are psychic and are able to read the minds of the PSR Committee members while you bill 1000s of kilometers away from them.

This is not the only problem. I and others who have gone through this process cannot legally share our specific experiences to support you all and educate our colleagues for these so-called 'inappropriate' billings either because of the silencing clauses in the current process. We are hoping that by bringing this to court, we will be able to rectify the ambiguity once and for all, allowing us as a profession to set our standards and continue to provide good healthcare for our patients without the fear of prosecution in an unfair manner.

Please share, contribute and come along to the trial. It is a fully fundraised trial so any support would be appreciated.

Here is the link to our GoFund Me page:

gf.me/u/vukvpj

I will be publishing more of these short articles with pearls from various clinicians who have gone through the PSR audit process in the coming future. Please feel free to email me and connecting with me if you have any further questions. If any PSR affected Doctors would like to contribute please PM me.