The core aspects of the compliance approach to support the stage one trial of Health Care Homes are foremost education and support, including the introduction of the Health Care Homes Funding Assurance Toolkit.
The Toolkit will assist Health Care Home staff to develop and implement policies, procedures, systems and day-to-day activities that will support the fostering of an effective Health Care Home funding assurance approach.
The key risk areas that will form the basis of Health Care Home compliance activities include:
- incorrect stratification of patients
- non-provision of Health Care Home services to enrolled patients
- systematic double billing under Health Care Homes and Medicare.
The following monitoring and management tools may be used by the department:
- Health Care Home completion of an annual assurance self-assessment tool to ensure that minimum program requirements are checked and reported on by the Health Care Home
- use of data and analytics to monitor enrolment and other patient claiming data
- conduct random audits and reviews.
It is expected that a number of Medicare Benefits Schedule (MBS) item services should not be claimed for Health Care Home patients as these services will be provided and funded through the Health Care Home bundled payment. For example:
- care planning, health assessment and care coordination services
- mental health planning and services
- telehealth support
- other clinical services such as respiratory function services, acupuncture, wound management, family group therapy and nurse practitioner consultation items.
It is also expected that the claiming of a number of MBS items will reduce for Health Care Home patients. For example:
- standard consultations
- home visits
- after-hours consultations.
MBS items for general practice services provided to residents of aged care facilities will also be reviewed to ensure Health Care Home patients who move into an aged care facility are withdrawn from the stage one trial.
MBS item 6087 facilitates the recording of an attendance for which a Health Care Home patient incurs an out-of-pocket expense for the treatment associated with the patient’s chronic or complex conditions, and for these out-of-pocket expenses to contribute to the patient’s Medicare Safety Net threshold. This MBS item will also be reviewed to ensure the item is only being used for Health Care Home patients and only for the purpose of recording out-of-pocket expenses incurred.
Assurance and compliance toolkit
The department has developed an assurance and compliance toolkit for practices and ACCHS participating in the stage one trial of Health Care Homes.