Bulk Bill quality checking processing 111-22090010

The Quality Control System (QCS) is used to select Medicare patient claim transactions and patient claim online transmissions, bulk bill vouchers and bulk bill online transmissions and public eligibility for quality checking and to record the results.

To interpret quality checking information on the QBBI screen, see The Quality Control System (QCS) for Medicare on the Resources page.

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)

Quality checkers must ensure that:

• bulk bill claims 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

Where source documents are hard copies, they must be held in the section 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 If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall the documents.

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 quality checks.

Before undertaking quality checking, selected staff members must:

• have knowledge of the relevant policies and procedures and where to source them
• complete the mandatory eLearning training MCA00802 - Claims and Eligibility Quality Checker
• complete and pass the Learning Portal assessment MCA00835 - Claims and Eligibility QC
• have reviewed the quality checking procedure and emailed the Manager advising they have been reviewed and understood
• undergo refresher training every 12 months

Only accredited Quality Checkers can undertake quality checking.

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

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.

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 bulk bill processing may be:

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

The Quality Control System (QCS) randomly selects 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

Note: in the online claiming environment, paperwork is replaced with:

• text (indicated by a 'T' in the service line on the history screen)
• DQRI bulk bill pend:
• DAPI
• DASI
• DEAI
• bulk bill latter day adjustment:
• DLAI
• DHAI

Note: where a bulk bill claim or online transmission is partially processed by one Service Officer and finalised by another, the QCS will display the vouchers or transmissions to be checked under the source code of the Service Officer who finalised the claim.

Scanned bulk bill vouchers and online bulk bill transmissions can be selected by the Quality Control System (QCS) when a Service Officer has manually intervened. This is to ensure compliance with business rules.

Note: in the online claiming environment, paperwork is replaced with:

• text (indicated by a 'T' in the service line on the history screen)
• DQRI control line (raw data for bulk bill)

Time frames

If quality checking for QBBI is not performed for a particular day, the work must be checked within 2 working days.

Resources

Bulk bill processing selected for quality checking may have been actioned from bulk bill vouchers, online claims or latter day adjustments.

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

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

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

Errors must be recorded and any follow-up action sent to the Service Officer for correction.

Document and processing errors

For the purposes of quality checking, a:

• document error is defined 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 defined 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

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
• be 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 procedures (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 of development in processing, gaps in business rules, issues relating to environmental factors and system faults and limitations
• complete an online Error Explanation Sheet (EES). See the Guide to completing the online Error Explanation Sheet on the Resources page

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.

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