Public Eligibility quality checking processing 111-22090030

QCS is used to select public eligibility transactions for quality checking and to record the results.

For how to interpret quality checking information on the QBBI screen, see The QCS for Medicare.

The objective of the quality checking procedure is to:

• give checkers the tools to be able to identify strengths and areas of development in the processing of Medicare public eligibility transactions
• highlight opportunities for continuous business improvement, using effective quality checking processes
• make sure Quality Checkers have the same understanding of the process
• ensure Quality Checkers are completing the checks in a consistent manner, by documenting the quality checking process

Managers/Team Leaders are responsible for ensuring:

• quality checking is performed on a daily basis for every processing day available on QBBI
• checkers have completed the appropriate training
• quality checks are undertaken as outlined in this procedure
• results of quality checks are recorded appropriately
• issues are addressed and corrections made immediately (see the Feedback section below)
• error feedback is discussed with Service Officer as part of the coaching conversation. This supports any learning and development needs
• positive quality checking results are discussed with the Service Officer
• lodgement of quality checking disputes (where applicable)

When source documents are hard copies, they must be held on site until the quality check is finalised. If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall the documents.

Quality Checkers must ensure that:

• Medicare public eligibility processing business rules have been applied correctly
• quality checking is performed on the specified sample size
• update and maintain technical knowledge, procedures and policies
• give constructive and non-judgemental feedback. Include reference materials such as Operational Blueprint
• explain the impact of errors and action to be taken to correct the error (where applicable) when giving feedback
• feedback is given to the processing Service Officer
• quality checking errors are recorded and reported using the online Error Explanation Sheet

Note: at the end of each month, quality checks (post-checking) must be completed by close of business (COB) on the first working day of the new month.

Quality checking of own work

Quality Checkers must not quality check their own work. If a Quality Checker's own work is selected, it must be passed to an accredited staff member to conduct the quality check.

Before undertaking quality checking, selected staff members must:

• successfully complete the training, MCA00802 - Claims and Eligibility Quality Checker and the assessment, MCA00835 - Claims and Eligibility QC
• have knowledge of relevant policies and procedures and/or know where to find them
• have reviewed the quality checking procedure and emailed the Manager/Team Leader advising they have been reviewed and understood
• undergo refresher training every 12 months

Only accredited Quality Checkers can undertake quality checking.

Pre-checks

New starters

Pre-checks proficiency requirements for new starters will be advised in the scope of training details.

Post-checks

Post-checks (QBBI) involve checking a statistically valid, random selection of work processed the previous day. The results are reported to executives and relevant stakeholders each month.

Targeted checks

In addition to the pre and post-checks, targeted checks (manual checking) provide an opportunity to look at other areas of the process.

Targeted checks for Medicare public eligibility processing may be:

• checks on staff members with identified quality issues
• Aim for Accuracy (separate procedure)

Post-checks

The Quality Control System (QCS) in the CICS mainframe randomly selects a number of public eligibility transactions for quality checking (QBBI). These transactions:

• are work processed the previous day
• are a selection of Service Officers from different source office codes
• appear under the legacy (CICS) transaction IDs

Any unactioned quality checking is not reported as part of the accuracy of processing Key Performance Indicators (KPI).

Multiple public eligibility processing activities selected for quality checking

When conducting quality checking, all public eligibility processing updates on the date of processing must be checked for accuracy and compliance.

If several updates have been performed in CDMS on the same Medicare card, QCS may select the same card multiple times on the same day.

In these cases, quality checkers must only populate one QCS transaction line with a valid status code.

All other selections should remain unactioned. They will no longer appear on QBBI after about 21 days.

Time frames

If quality checking for QBBI is not performed for a particular day, the work must be checked within 2 working days. Outstanding transactions are to be completed prior to selecting another day’s processed work.

At the end of each month, quality checks (post-checking) must be completed by close of business (COB) on the first working day of the new month.

Resources

Public eligibility processing updates selected for quality checking may have been actioned from several different types of source documentation. This includes:

• Medicare Enrolment Application forms
• Medicare Copy/Transfer Application forms
• Medicare Safety Net forms
• written correspondence
• family assistance forms including digital images
• Australian Organ Donor Register (AODR) forms
• Australian Immunisation Register (AIR) forms

Recording confirmation of details

When a public eligibility processing request has insufficient or incomplete information, a Service Officer may be required to confirm information with a member of the public over the phone. To notate this information add comments in PaNDA and CDMS.

Service Officers must not write on family assistance forms.

Quality checkers must follow the appropriate escalation process for the relevant programme.

Quality, Performance and Technical Support is only responsible for the management of the quality checking procedures.

Quality Checkers requiring clarification on processing business rules should follow the appropriate escalation process for the relevant programme.

Eligibility errors, except My Health Record, must be recorded and any follow-up action sent to the Service Officer for correction.

My Health Record error information must be sent via email to the My Health Record Support team for correction.

Document and processing errors

For quality checking:

• document error is when a Service Officer has processed the transaction and has not detected that the original paperwork was incomplete or contained insufficient information to support the action taken
• processing error is when a Service Officer has processed or entered information incorrectly which does not match the original paperwork submitted

Errors should be identified during the quality checking process (post-checks) by following the steps outlined in the program quality checking procedure.

Quality checkers are required to record the following:

• QBBI - only the error that is deemed to have the greatest impact
• Error Explanation Sheet - all errors
• My Health Record errors - the MHR error email template must be completed and sent to My Health Record Support for action

All quality checking results (post-checks) are reported to executives and relevant stakeholders each month.

Post-checking results recorded by each program are measured against respective, endorsed key performance measures. Each program is expected to meet or exceed their endorsed key performance measure.

Each time a quality check is completed, the Quality Checker must provide feedback to the Service Officer and their Team Leader advising them of the outcome. This feedback should be:

• positive for transactions identified as error-free
• given the same day or as soon as possible after the quality check is completed
• describe the error identified, and what was incorrect
• explain the action that should be taken to correct the error
• include any relevant reference material that supports the action, such as Operational Blueprint details if available

In consultation with the processing Service Officer, the Quality Checker is to:

• determine the reason(s) for the error (underlying factors)
• identify any possible areas for development, gaps in business rules, issues relating to environmental factors and system faults and limitations
• (for My Health Record errors) complete the email and send to My Health Record Support
• complete an online Error Explanation Sheet (EES). See the Guide to completing the online Error Explanation Sheet

If errors have been identified, action must be taken to correct the error. Errors are to be corrected by the original processing Service Officer. Where corrections cannot be made by the original processing Service Officer, the Team Leader will be responsible for ensuring the corrections are undertaken.

Recurring errors must be brought to the attention of the:

• Manager/Team Leader of the processing area, and
• Service Officer concerned

Remedial action (such as training) needed to reduce the occurrence of errors should be planned by the Manager/Team Leader and undertaken as a matter of priority by the Manager/Team Leader.

Quality checking procedures are regularly reviewed and updated by the respective programs in consultation with the Quality, Performance and Technical support team. This incorporates endorsed changes to program business policy and procedures and ensures that error codes are current and appropriate.