Patient Claims quality checking processing 111-22090020

A patient claim involves the claimant and the patient. The medical service is provided to the patient. The Medicare benefit is paid to the claimant for fully paid accounts or to the provider for unpaid or partially paid accounts. Both are mandatory components of the claiming process however they do not have to be the same person or on the same Medicare card.

Quality checking for patient claims involves checking a random sample of patient claims transactions to see whether the program business rules have been applied correctly.

The Quality Control System (QCS) is used to select Medicare patient claim transactions and patient claim online transmissions for quality checking and to record results.

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

The purpose of the patient claims quality checking procedure is to:

• give quality checkers the tools to identify strengths and areas of development in the processing of Medicare patient claims
• highlight opportunities for continuous business improvement, using effective quality checking processes
• ensure Quality Checkers:
• have a consistent level of understanding about the process
• complete 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 the 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)

Where 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 If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall them.

Quality Checkers must make sure that:

• Medicare patient 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 actions to be taken to correct the error (where applicable) when giving feedback:
• 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, Service Officers must:

• successfully complete the training MCA00802 - Claims and Eligibility Quality Checker
• 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
• undertake reaccreditation as required

Only accredited Quality Checkers can undertake quality checking.

Pre-checks

Pre-checks are used while Service Officers complete the training to help determine 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 patient claims processing may include:

• checks on Service Officers with identified quality issues
• Aim for Accuracy (separate procedure)

Post-checks

The Quality Control System (QCS) randomly selects some patient claims transactions for quality checking (QBBI). These transactions:

• are work processed the previous day
• are a selection of Service Officers from different source office codes
• include manual patient claims from any patient claim processed using the following suite of transactions:
• NP**
• NH**
• NS**
• NE**
• include online patient claims where a Service Officer has manually intervened

Note: an online patient claim may be partially processed by one Service Officer and finalised by another. The QCS will place the claim to be checked under the source office code of the Service Officer who finalised the claim.

Multiple patient claims transactions selected for quality checking

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

For transactions with:

• the same time stamp, the first transaction line with a valid status code is actioned and the additional unactioned transaction line(s) should remain unactioned. They will no longer appear on QBBI after 21 days
• different time stamps, all transaction lines are actioned. If an error is identified in each transaction line, the relevant error status code must be applied against the corresponding time stamp

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

Medicare patient claims processing updates selected for quality checking may have been actioned from many different types of source documentation. This includes:

• Medicare mainframe
• Medicare claim forms
• Invoices
• Receipts
• Online claims
• Text messages

Quality and Skill Tags is only responsible for the management of the quality checking procedures.

Quality Checkers requiring clarification on processing business rules must follow the appropriate escalation process for the relevant program outlined in Operational Blueprint.

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

Document and processing errors

For quality checking, a:

• document error is when a Service Officer has processed the transaction and:
• has not detected the original paperwork was incomplete, or does not hold
• enough details to support the action taken
• Note: if fraud is suspected during the quality checking process, quality checkers must follow the process in Suspected Medicare fraud and Business Integrity (BI) flags and report it
• processing error is when a Service Officer has processed or entered details 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 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 required to correct the error
• include any relevant reference material that supports the action, such as Operational Blueprint

Feedback questions and escalations

• If the Service Officer needs clarification or disagrees with the error received, they must 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 for development, gaps in business rules, issues relating to environmental factors, 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 errors. Errors are to be corrected by the original processing Service Office. 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 Tags team. This incorporates endorsed changes to program business policy and procedures and make sure error codes are current and appropriate.