13 April 2023

Medicare should lead the charge ahead of PMS changes 

Medicare Political

The recent Medicare Integrity and Compliance review called for Practice Management Systems (PMS) to block to Medicare fraud and non-compliance in real-time, but industry says Medicare should get its own house in order first. 

Emma Hossack, CEO of the Medical Software Industry Association (MSIA), responded to the independent review and agreed that things need to change. However, she said that Medicare requires an overhaul before PMS functionality can change. 

“Medicare needs to get its systems upgraded and co-designed with its primary users – PMS – before any changes are made to them.  Otherwise, it would be like asking all drivers to get cars capable of driving over sink holes rather than fixing the problem,” Ms Hossack said. 

Ms Hossack told Wild Health that “most parties” would agree that there are multiple Medicare legacy systems which constantly present Services Australia with “significant obstacles to efficiency and a good UX”. 

She cites the upcoming Prosthesis List Reform as an example. 

“Eclipse, which is run by Services Australia, will need to be able to identify each item, in a yet-to-be specified bundle, to process it for payment. Doing this without flexible architecture will make it very difficult to achieve by the deadline of 1 July 2023,” she said. 

Despite all the barriers, Ms Hossack also said not to underestimate what has previously been achieved through concerted, collaborative efforts by Services Australia and the health software industry. 

“Getting the Adaptors to Web Services working, and the covid19 response with uploads to the Australian Immunisation Register was huge. It shows what is possible [with collaboration], though it is largely unsung,” she said. 

Ms Hossack was clear that collaboration with the medical software industry is the best way to make future fixes effective. 

“Sadly, the Medicare Integrity and Compliance review didn’t speak to us about that as industry was not invited to contribute to this review. It’s ironic really, given that?the whole claiming process would grind to a halt without MSIA members technology,” she said. 

The review recommended that PMS technology to become part of a “first line of defence” for compliance and integrity

Recommendation 4.1 called for PMS integration with the Medicare claims assessment rules engine. This would enable “real-time claims assessment” by a PMS, and reduce unintentional, non-compliant claiming.  

Along with recommendation 4.2, “Implement technology to enable consistent and complete pre-payment checking and validation of all MBS claims as part of the first line of defence,” non-compliance and fraud would be detected and blocked prior to a claims submission. 

Ms Hossack said that PMS do currently have “a lot of smarts to assist users checking” but she added that synchronous checking could seriously degrade the performance of an old system “if everyone was constantly polling it”.  

Ms Hossack said that proposition for real-time assessment also assumes that all GPs have excellent internet and no redundancy, and that Medicare never suffers outages. 

“There have been very significant costs to industry attributable to Medicare outages,” Ms Hossack told Wild Health. She referred to statistics from one company which showed a Medicare outage prompting hundreds of customer calls within a few days. The company had to respond to these calls at their own time and cost, despite having not created the error.  

“There is a fix. Services Australia can send out immediate notification to all GPs and industry. It would save a fortune. We look forward to that happening,” Ms Hossack said. 

The solution to Medicare’s technology woes requires a major shift in thinking, Ms Hossack told Wild Health. She is “super positive” about Minister Bill Shorten advocating for the value of real-time, distributed architecture following his study trip to Europe last year.  

“He recently promoted a service orientated architecture to create an efficient ecosystem rather than a vulnerable honey pot of a one-size-fits-all, that often fits nobody,” Ms Hossack said. 

She told Wild Health that a federated, service orientated architecture is what industry has been advocating for, 10 years after the failure of NpfIT – the UK’s National Programme for IT. 

“It is a philosophical leap to think of health – and therefore the systems that support it – working as a federation, rather than jumping immediately to centralisation to solve the perceived problem. Let’s hope they can make that leap,” Ms Hossack said.