1. Contributing to the Integrity of the System
March 2015
Contributing to the Integrity of the System
Medicare Compliance
Presented by Barry Sandison, Deputy Secretary, Health, Compliance and Information

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.

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

4. Our Health Compliance Model
High
Prosecute
High
Level of Compliance Costs
Detect and review
Level of Risk
Remind and Alert
Help and Educate
Low
Low
Compliance Strategies

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

6. The move to online
Over 360 million services generated through about 39,000 health practices in , 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).

7. Its all about the data

8. 2014 - Claiming for MBS Services and Benefits
Benefit
Services
Professional Attendances
$ ,038,404,921
170,800,157
Therapeutic Procedures
$ ,286,199,746
22,732,845
Diagnostic Imaging Services
$ ,056,663,948
23,480,345
Pathology Services
$ ,541,744,288
127,397,445
Miscellaneous Services
$ ,323,291,479
11,126,775
Diagnostic Procedures and Investigations
$ ,460,822
6,514,133
Dentist, Dental Specialist and Dental Prosthetists & Dental Benefits Schedule
$ ,401,720
4,474,445
Oral and Maxillofacial Services (by Approved Dental Practitioners)
$ ,647,679
102,049
Cleft Lip and Cleft Palate
$ ,936,493
8,183
Total
$ ,020,751,096
366,636,377

9. Indicators: Potential Anomalous Claiming Patterns

10. Indicators: Outside Scope of Practice
Odd one out - rendering services unusual for that specialty
Top 100 data
High servicing
Low servicing

11. Indicators: Inadequate clinical input
Too many hours in a day
Too many patients in a day
Too many investigations
Too many procedures

12. Update - Key Recent Enhancements
Enhanced Risk Identification and Prioritisation
Moving from process to task activities.
Key risk topics for , include Pathology, Diagnostic Imaging, Specialists, General Practitioners, Public Fraud.
Outcomes Monitoring Framework
Demonstrable increase in performance: total debts and behavioural change.

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.

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.

15. Collaboration Dissemination of intelligence.
Dissemination of best practice.
Increased engagement/consultation.