Medicare to block staff fee tampering

Following an audit by the Australian National Audits Office (ANAO), Medicare has agreed to tighten its claims processing system to prevent staff tampering with claims.

Following an audit by the Australian National Audits Office (ANAO), Medicare has agreed to tighten its claims processing system to prevent staff tampering with claims.

The ANAO audit, released yesterday, has recommended the agency tighten the automated rules applied to its claims processing system in order to improve compliance.

The audit recommended that Medicare amend its claims processing system to prevent inappropriate access to fields such as "Item Fees" on Medicare claims under assessment. Medicare has also agreed to prevent staff overriding the transaction system's business rules when not authorised to do so.

ANAO discovered during the audit that Medicare had failed to apply end-dates to some of the automated business rules which govern the assessment of Medicare claims, thereby exposing claimants to the risk of inconsistent decisions by Medicare staff.

Medicare currently lacks a system to analyse incoming information in order to detect ambiguities in its assessment process, leaving staff without the ability correct such mistakes, according to the audit.

However the audit also found Medicare is gaining efficiencies by increasing the number of claims being lodged online, reducing paper handling and scanning requirements.

The audit revealed that the number of claims being lodged online has steadily increased over the past four financial years, from zero in the 2002-2003 financial year to 24 percent in 2006-2007.

Two key initiatives that have driven this shift to online submissions are Medicare Online -- for patients -- and Electronic Data Interchange, used by health insurance providers to submit claims on behalf of members.

Last year Medicare's claims processing system processed over 250 million medical claims, worth AU$11.8 billion in benefits. The agency has agreed to implement all of ANAO's recommendations.

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