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 the following transactions/transmissions for quality checking and to record results:

• Medicare patient claim transactions and patient claim online transmissions
• bulk bill vouchers and bulk bill online transmissions
• public eligibility

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

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

• give checkers the tools to:
• identify strengths and areas of development in the processing of Medicare patient claims, and
• 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
• checking is undertaken by accredited Quality Checkers
• 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 If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall them.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 ensure:

• they correctly apply Medicare patient claims processing business rules
• quality checking is performed on the specified sample size
• they update and maintain technical knowledge, procedures and policies
• they give constructive and non-judgemental feedback to Service Officers, including reference materials such as Operational Blueprint
• when giving feedback, they explain:
• the impact of errors, and
• action needed to correct the error (where applicable)
• quality checking errors are recorded and reported using the online Error Explanation Sheet

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.

See Resources for a link to the Error Explanation Sheet.

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 checks.

Before undertaking quality checking, selected staff members must:

• successfully complete the training MCA00802 - Claims and Eligibility Quality Checker and 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 - Proficiency checking is determined by the training plan established for the training group. Plans may vary based on business drivers and previous staff experience.

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 patient claims processing may be:

• checks on staff members 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:

• two-way claims should be left un-actioned by the Quality Checker
• 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 transaction line(s) un-actioned
• different time stamps, all transaction line are actioned. If an error is identified in each transaction line, the relevant error status code must be applied against the corresponding time stamp

All un-actioned quality checking items will no longer appear on QBBI after approximately 21 days.

Time frames

If quality checking for QBBI is not performed for a particular day, the work must be checked within two working days. Outstanding transactions must be completed before selecting another day's processed work.

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

Resources

• Medicare mainframe
• Operational Blueprint
• Source documentation
• Medicare claim forms
• Invoices
• Receipts
• Online claims
• Text messages

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

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

Quality Checkers who need clarification on processing business rules must follow the appropriate escalation process for the relevant program.

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

Document, processing and referral errors

For the purposes of quality checking, a:

• document error is when a Service Officer has processed the transaction and:
• has not detected the original paperwork was incomplete, or
• it did not contain enough details to support the action taken
• processing error is when a Service Officer processes or enters information incorrectly, that is, it does not match the original paperwork submitted
• referral error is when a Service Officer identifies an anomaly that might warrant a referral to Health Compliance

Quality Checkers must record any errors identified during the quality checking process (post-checks). The steps outlined in the program quality checking procedure must be followed.

Errors should be identified during the quality checking process (post checks). The steps outlined in the program quality checking procedure must be followed.

Quality checkers must 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.

See Resources for a link to the Error Explanation Sheet.

When a quality check is completed, the Quality Checker must provide feedback to the Service Officer and their Team Leader advising the outcome. 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 details (if available)

In consultation with the processing Service Officer, the Quality Checker or Manager/Team Leader:

• determines the reason(s) for the error (underlying factors)
• identifies any possible:
• areas for development
• gaps in business rules
• issues relating to environmental factors, and
• system faults and limitations
• completes the Error Explanation Sheet. See Resources for:
• an intranet link to the Error Explanation Sheet, and
• the attachment, Guide to completing the online Error Explanation Sheet

If the Quality Checker identifies errors, the original processing Service Officer must correct the errors. If they cannot correct them, the Team Leader must make sure the corrections are made.

Recurring errors must be brought to the attention of the:

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

To reduce the occurrence of errors, the Manager/Team Leader should plan and manage remedial action (such as training), as a priority.

Quality checking procedures are regularly reviewed and updated by the respective programs in consultation with the Quality, Performance & Technical Support team. The review ensures:

• error codes are current and applicable, and
• approved changes to program business policies and procedures are included