PBS manual pharmacy claims quality checking in QST 111-21031518

The PBS manual pharmacy claims checking process aligns Services Australia's Enterprise Quality Framework and the 7 quality principles.

See Resources for a link to the Enterprise Quality Framework.

The quality checking process:

• helps Team Leaders and Quality Checkers to identify process improvements
• ensures consistency in quality checking

PBS Quality Portfolio Holder is responsible for:

• national implementation of PBS quality practices
• analysis of national quality reports to identify learning needs or process improvement opportunities
• escalation of national quality issues to the program area and/or to Quality Operations & Technical Support

Managers/Team Leaders must make sure:

• Quality Checkers complete the process for Quality Checker accreditation
• Quality Checkers hold appropriate skill tags in the Quality and Support Tool by sending an email to Quality Operations & Technical Support
• error feedback is discussed with Service Officer as part of the coaching conversation. This supports any learning and development needs
• they analyse any errors. For example, did the errors occur because there is limited training, understanding of the business rules, environmental or system based issues
• positive quality checking results are discussed with the Service Officer
• they analyse data to identify learning needs or process improvement opportunities
• quality checks are done as specified in the sampling plan
• they escalate serious quality issues, for example, report all privacy breaches using the Privacy incident portal on the Resources page
• they escalate systemic issues
• lodgement of quality checking outcomes disputes

Quality Checkers must:

• carry out quality checks as outlined in the sampling plan
• update and maintain technical knowledge, procedures and policies
• maintain a correctness standard for personal accuracy
• complete root cause analysis and identify systemic issues
• report and escalate trends or concerns to their Team Leader
• 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
• examine system information/source documents to make sure claims processes are in line with PBS business rules, policies and procedures
• make sure they do not check their own work. If a quality checker’s own work is selected, it must be passed to another accredited checker to check

Quality Team must:

• provide support for quality checking in the QST
• provide relevant reports as needed
• arrange QST training for Quality Checkers
• support the business with flexible and fit for purpose quality approaches
• support provisions of accredited quality checking training

Quality Checker accreditation must be renewed annually. See Quality Checker accreditation for Health Service Delivery Division for more information.

To be accredited, Quality Checkers must:

• have knowledge of relevant policies and procedures
• maintain a high correctness standard in the program they are checking
• have an understanding of the quality checking procedure for PBS manual pharmacy claims
• meet accreditation standards annually
• renew Quality Checker accreditation annually

Pre-checks

Pre-checks apply:

• to new starters
• when new processes are introduced

New starters have 100% of their work reviewed and corrected until deemed proficient. Any errors made in pre-check must be recorded as errors. Results are used to support ongoing training.

Program/post-checks

Program/post-checking randomly selects work completed the previous business day in Processing and National Demand Allocation (PaNDA). The results are provided to management and external stakeholders as needed.

Targeted checks

Targeted checks apply to:

• staff, when there is a substantial new process introduced or an identified quality issue
• Aim for Accuracy process (Check the Checker) which is completed every 12 months. This confirms the accuracy of quality checking results. The process involves rechecking a sample of previously checked work to decide if quality checking procedures have been followed correctly

Pre-checks

Staff have 100% of their work checked until they become proficient. As a guide, new starters are considered proficient when:

• 5 PBS manual pharmacy claims or 25 prescriptions are 100% error free
• 3 lost prescription claims (statutory declaration work) are 100% error free

This can include real or simulated work.

These numbers can be reduced. If this occurs staff must pass a skills assessment in lieu of the residual requirements.

Program/post-checks

• 2% of the monthly total of PBS manual pharmacy claims are randomly selected for quality checking
• For large claims the Quality Checker checks for 30 minutes (starting at the end of the claim). This gives a representative sample of the claim’s quality
• A large claim may have been actioned by a number of operators. The Quality Checker must check PaNDA comments to see where each operator started and finished processing
• The outcome of the quality check is provided to the operator who finalised the claim and based on their work only. Any errors by earlier operators is provided to them as feedback only
• There are no program checks for lost prescriptions or statutory declaration work. These work types are scrutinised by a delegate before payment is made

Targeted Checks

To arrange a targeted check(s), Team Leaders send an email request to Quality Operations & Technical Support with the:

• staff member’s details
• the reason and length of time required for the targeted check

Timeframes

Quality checks are undertaken daily on a random sample of work.

• Pre-checks - quality checks are normally done within 1 business day of the work being completed
• Programme checks - where possible, quality checks are completed within 4 calendar days of being allocated in the QST. At the end of the month, any program check not completed is automatically abandoned after 4 calendar days

Resources

Quality checkers must have access to the following to do quality checks:

• program specific processing systems
• Processing and National Demand allocation (PaNDA)
• Quality and Support Tool (QST)
• skill tags added to QST
• Mainframe
• Schedule of Pharmaceutical Benefits
• PBS Claims Processing system
• FileNet

An error is information processed or keyed that does not match the documents supplied, or the supporting documents uploaded on the systems.

Critical and non-critical errors

Error codes are categorised as critical and non-critical.

A critical error is when there is a potential risk to:

• a customer's:
• privacy
• eligibility
• payments
• application assessment being finalised
• record
• the agency's reputation

A non-critical error is when it does not impact the above criteria. Generally, this relates to administrative errors.

Only critical errors are used to calculate the health status of the program.

Each time a quality check is completed, the Quality Checker records the outcome in the Quality and Support Tool (QST). A system-generated email is sent in real time to the Service Officer and their Team Leader advising them of the outcome. Individual results are captured in QST.

Feedback is emailed to the Service Officer and their Team Leader. It gives details about the:

• check
• result (including any errors identified)
• quality checking dispute process

Method for managing and storing feedback

Feedback is recorded/stored in the Quality & Support Tool. Discussion notes about the feedback should be detailed in coaching sessions.

Correcting Errors

Critical errors - Quality Checkers must correct critical errors immediately as they are found.

Non-critical errors - Quality Checkers provide instruction in the feedback email for Service Officers to correct non-critical errors.

Quality Checkers must consult their subject matter experts for questions about PBS manual pharmacy claims.

Enquires about the quality checking process or issues with checking results that cannot be resolved on site should be directed to Quality Operations & Technical Support by email.

Quality checking procedures are reviewed and updated by the business and program in consultation with Quality Operations & Technical Support. The review makes sure

• error codes are current, and
• approved policy changes are included

Any changes that need immediate action will be advised and updated accordingly. Any changes not critical to quality will be incorporated in the review of the procedures.