Bulk Bill quality checking processing 111-22090010

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

For information on how to interpret quality checking information on the QBBI screen, see Resources for a link to The Quality Control System (QCS) for Medicare.

The purpose of the quality checking procedure is to:

• give quality 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
• ensure Quality Checkers:
• have a consistent level of understanding about the process
• complete the checks in a consistent manner, by documenting the quality checking process

Managers/Team Leaders are responsible for ensuring:

• quality checking is performed daily for every processing day available on QBBI
• quality checkers have completed the relevant 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 If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall the documents.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 make sure that:

• bulk bill claims processing business rules have been applied correctly
• quality checking is performed on the specified sample size, randomly selected by the Quality Control System (QCS)
• 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 Medicare Error Explanation form

Quality checking of own work

Quality checkers must not quality check their own work. The quality checker’s own work will not appear on the QBBI Mainframe screen.

Before undertaking quality checking, services officers must:

• successfully complete the mandatory eLearning training MCA00802 - Claims and Eligibility Quality Checker
• have knowledge of the relevant policies and procedures and where to find them
• have reviewed the quality checking procedure and emailed the Manager advising they have been reviewed and understood
• undertake re-accreditation as required

Only accredited Quality Checkers can undertake quality checking.

Pre-checks

Pre-checks are used while Service Officers complete training to help with determining proficiency requirements.

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

As well as 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 include:

• checks on Service Officers 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

QBBI items are ideally checked within 2 working days. This ensures customer outcomes are met, and staff receive timely quality outcomes. Outstanding QBBI items must be completed before selecting the recent day’s processed work for quality checking.

Any unactioned QBBI items that are not quality checked after 21 days will be automatically removed from the system.

Resources

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

Quality and Skill Tags team 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 program outlined in Operational Blueprint.

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. See Medicare claims and eligibility quality checking.

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

Each time a quality check is completed, the Quality Checker must send an email to the Service Officer and their Team Leader advising them of the outcome. Quality checkers must use the appropriate standard feedback email templates. See the Resources page for the templates.

This feedback must:

• 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

Feedback questions and escalations

• If the Service Officer needs clarification or disagrees with the error received, the Service Officer needs to discuss this with their Team Leader
• After discussion with the Team Leader, follow the quality checking dispute process

The Quality Checker must:

• identify any possible areas of development in processing, gaps in business rules, system faults and limitations
• complete the Medicare Error Explanation form. See Resources for a link

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 by way of feedback to 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.

Respective programs regularly review quality checking procedures in consultation with the Quality and Skill Tag team. This incorporates endorsed changes to program business policy and procedures and ensures that error codes are current and appropriate.