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Wednesday, 2 November 2011
Page: 8079

Chronic Disease Dental Scheme

(Question No. 1227)


Senator Bushby asked the Minister representing the Minister for Human Services, upon notice, on 20 September 2011:

In regard to the Medicare Chronic Disease Dental Scheme (CDDS):

(1) What is the scheduled fee paid to general practitioners (GPs) for each referral under the CDDS.

(2) How many practitioners have been: (a) audited; and (b) found to be non-compliant.

(3) What are the main reasons for breaches in compliance.

(4) By financial year, what is the total amount paid out under the CDDS since its inception, and how does this compare with that budgeted for each respective year.

(5) What is the total amount paid to dental practitioners since its inception, and every year.

(6) How many dentists have had to, or will have to, make re-payments and what is the procedure for making

re-payments.

(7) When was the decision made to undertake audits of the scheme and/or compliance by participating dentists in the CDDS.

(8) (a) Who decided to undertake the audits; (b) was it decided to do so at a departmental level or was the decision made by the Minister; (c) why was the decision taken; and (d) if the decision was not made by the Minister, was the Minister or the Minister's office consulted prior to the decision being made.

(9) Given the initial decision to conduct audits of the scheme and/or compliance by the participating dentists: (a) how many audits were initially to be carried out; (b) on what basis would dentists be selected for audit; (c) what resources were made available to conduct the audit; and (d) from what budgetary measure were those resources sourced.

(10) Since first deciding to conduct these audits, has any decision been made to vary the number of participating dentists to be audited; if so, on what basis and for what purpose.

(11) Has the department conducted any assessment of the total amount paid out under the scheme that is likely to be recovered as a result of the audit process and related follow-up of audited dentists; if so, can the results of that assessment be provided.

(12) What programs or other actions did the department conduct or take to ensure that dentists participating in the CDDS were fully aware of the terms on which they participated and what their obligations were under the CDDS.

(13) What is the difference between dentists being asked to participate in 'information gathering' and undergoing an audit.

(14) How many practitioners found to be non-compliant have been given a caution.

(15) If a dentist is required to participate in 'information gathering' does this preclude the department from undertaking an audit; if not, how does Medicare ensure they are given a fair audit in light of the information they have already provided.

(16) How specific was the education in respect of dentists' obligations regarding the administrative requirements under the CDDS.

(17) What were the dates of these programs and or other actions.

(18) As part of any of those programs, were participating dentists specifically educated about the consequences of non-compliance; if so, how (for example, in writing).

(19) Were dentists advised at any time that failure to comply in all respects with the administrative requirements under the CDDS would result in their being required to repay monies received under the scheme; if so, how and when were they advised and what steps were taken to ensure that all participating dentists were advised.

(20) Where audits have found irregularities, what processes are taken to assess whether those irregularities should result in repayments by the dentists concerned.

(21) Where audits have found irregularities, have any dentists been re-educated on their obligations under the CDDS and not asked to repay any or all of the related monies paid under the scheme; if so, how many dentists and for what amounts.

(22) Why are all monies being reclaimed, including treatment expenses.

(23) How has the projected number of cases referred by GPs each year compared to the actual number of referrals under the CDDS since its inception.

(24) Has the Government taken into consideration issues raised by stakeholders, including that the CDDS is not means tested, and that the sole criteria for eligibility was through a GP identifying that a patient had a chronic disease and that dental treatment may alleviate the illness.

(25) Are administrative oversights by dentists being used to penalise them even though treatments have been legitimately provided.

(26) Why did Medicare wait more than 2 years to embark on any research as to dentists' compliance with these administrative requirements.

(27) Why was it not until the Australian Dental Association met with Medicare in early 2010 that any education program was embarked on in respect of these administrative requirements.

(28) Why, when the services have been legitimately provided by dentists, has Medicare demanded repayment from dentists of monies received under the CDDS instead of just asking that the paperwork deficiencies be addressed.

(29) How many times has Medicare received a complaint from a GP that a dentist has failed to provide a treatment plan to them.

(30) Is the Minister aware of any dentists who have been audited under this scheme, since having taken their own life.


Senator Arbib: The Minister for Human Services has provided the following answer to the honourable senator's question:

(1) In order to access benefits under the CDDS, a patient needs to be managed by their GP under certain care plans and must be referred by their GP for dental services. For most people, this involves the preparation of a "GP Management Plan" (MBS item 721) and "Team Care Arrangements" (MBS item 723). For residents of aged care facilities, it involves the GP contributing to a multidisciplinary care plan (MBS item 731) prepared for the resident by the facility.

Under the Medicare Benefits Schedule (MBS), a benefit of $136.05 (100% of the MBS fee for item 721) can be paid for a GP to complete a GP Management Plan, and a benefit of $107.80 (100% of the MBS fee for item 723) can be paid for completing and implementing Team Care Arrangements. Alternatively, if the patient is in a Residential Aged Care Facility, the GP is paid for contributing to or reviewing a multidisciplinary care plan (100% of the MBS fee of $66.35 for MBS item 731). After the relevant services above have been completed, the GP can refer the patient for treatment under the Chronic Disease Dental Scheme.

(2) 60 audits of dental practitioners have been completed. Of the 60 completed audits, 39 have been found non-compliant.

(3) There are two main areas of non-compliance by dental practitioners:

dental practitioners claiming Medicare benefits for services not provided (this includes, services never provided and services which have not been completed); and

failure to fulfil the requirements of section 10 of the Health Insurance (Dental Services) Determination 2007 (the Determination) by failing to provide a written quote and treatment plan to the patient, prior to commencing the course of treatment, and failure to provide a copy or summary of the treatment plan to the referring GP, prior to commencing the course of treatment.

(4) The figures are as follows:

 

Nov 2007 - Jun 08

2008-09

2009-10

2010-11

2011-12

(to 31 August 2011)

Total

Actual claims made under CDDS

$88.7 million

$364.1 million

$576.5 million

$726.4 million

$144.8

million

$1.90 billion

 

The CDDS forms part of the special appropriation for the MBS and is not separately provided for in the Budget.

(5) See table at question 4.

(6) 32 dental practitioners will have to or had to make repayments in relation to their incorrect claiming behaviour.

Following completion of the audit the dental practitioner is advised of the amount to be repaid in writing, to which the dentist has 28 days to respond. Once the incorrectly claimed amount is confirmed, the amount is formally raised as a debt to the Commonwealth. There is a sequence of correspondence in relation to the debt process. These are as follows:

Notification of debt to the dental practitioner;

A follow-up letter reminding the dentist about the debt if no response to the first letter has been received within 30 days; and

A final follow-up letter reminding the dentists about the debt if no response was received within 14 days from the date of the second letter. The dental practitioner then has seven (7) days to respond.

After this point, if no response has been received from the dental practitioner, the Department of Human Services - Medicare may:

refer the matter to a debt collection agency;

initiate legal proceedings; or

write off the debt under the Financial Management and Accountability Act 1997.

(7) In November 2008, Medicare Australia (Medicare) commenced compliance activities to determine the level of compliance with requirements of the Chronic Disease Dental Scheme (the scheme).

(8) (a) The decision was made as part of Medicare's annual National Compliance Program.

   (b) The decision was made at a departmental level.

   (c) Medicare determined through initial compliance activities and the analysis of complaints received, that claiming practices under the Chronic Disease Dental Scheme represented a significant risk to the integrity of the program.

   (d) The Minister's office was not consulted prior to the initial decision being made.

(9) (a) Audits were initially conducted on 49 dental practitioners, comprising 28 dental practitioners that were considered high risk following analysis of their claiming profile, and a further 21 dental practitioners who had been brought to Medicare's attention through the fraud tip-off line as the direct result of complaints received.

   (b) The dental practitioners are identified for audit as a result of their high levels of claiming in terms of both volume and dollar value compared to their peers and/or as a result of complaints received.

   (c) The resources were made available from existing operational compliance teams as part of Medicare's annual National Compliance Program.

   (d) The resources were drawn from the existing compliance operational budget.

(10) Following the initial audits, the department has 419 audits underway as at 21 September 2011. The majority of these audits are the result of complaints received by the department or on the basis of high claiming patterns by dental practitioners.

(11) The department has not conducted any such assessment.

(12) I refer the Senator to documents tabled on 18 October 2011.

(13) In the case of 'information gathering' activities, a dental practitioner's participation is voluntary and therefore he/she may choose to decline to participate. In the case where a dental practitioner has been selected for an audit, either in relation to a complaint or as the result of claiming behaviour, the audit is conducted even if the dental practitioner elects not to participate. Where the dental practitioner elects not to participate in the audit, the audit is conducted by verifying compliance through third party sources.

(14) 7 dental practitioners have been provided with educational information about correct claiming practices.

(15) Participating in 'information gathering' activities does not preclude a dental practitioner from future audits.

The department ensures all dental practitioners are given a fair audit by:

Providing proper notification and explanation of audit processes;

Delivering audits in a professional manner; and

Giving a dental practitioner the opportunity to comment, seek advice or clarification, or provide further information throughout the audit process, including the opportunity to comment on the audit outcome and to request a review of the audit outcome.

(16) Both the fact sheet and the Dental Services Book sent to members of the dental profession in 2007 stated clearly the obligations of dental practitioners in regards to the requirements of the Chronic Disease Dental Scheme. The information included:

that a copy or summary of a treatment plan must be provided to the GP at the beginning of treatment and that a written quote and treatment plan must be provided to the patient prior to beginning the treatment.

a checklist of steps for the dental practitioner to ensure they comply with the requirements of the scheme, as well as a Medicare Enquiry Line for dental practitioners who wished to seek advice.

(17) The key actions that were undertaken are:

In September 2007, the then Minister for Health and Ageing (the Hon Tony Abbott MP) wrote to dental practitioners, dental specialists and dental prosthetists introducing the scheme. The correspondence also advised that a requirement of the program is that patients must be informed of the cost of dental services prior to commencing treatment.

In October 2007, the Department of Health and Ageing wrote to dentists, dental specialists and dental prosthetists providing a fact sheet and the Medicare Benefits Schedule Dental Services book that included a checklist of requirements for claiming under the scheme.

In December 2009, Medicare provided the Australian Dental Association with an information sheet which was published in their January 2010 publication.

Medicare wrote to all dental practitioners on 10 June 2010 to describe the compliance activities being undertaken and explain the current concerns with the use of the Chronic Disease Dental Scheme.

On 29 April 2011, the then Chief Executive Officer of Medicare Australia sent a letter to all dental practitioners who had claimed under the Chronic Disease Dental Scheme. The letter highlighted the main concerns of non-compliance; reminded dentists of their obligations under the Scheme; and informed them of the increased audit activity.

(18) Yes. This was contained in the Dental Services Book provided at the commencement of the scheme.

Prior to submitting claims for any benefits under the Medicare Benefits Schedule it is the responsibility of health professionals to understand the requirements and ensure their claims are fully compliant. The requirements for the Chronic Disease Dental Scheme are consistent with these general obligations on all health professionals.

(19) The Dental Services Book states that 'where a Medicare benefit has been inappropriately paid, Medicare Australia may request recovery of that benefit from the practitioner concerned'.

(20) All Medicare audits take into consideration the individual circumstances of each dental practitioner and the case outcomes are based on the individual merits and findings of each audit.

(21) 7dental providers have been found non-compliant with regard to the legislative requirements for claiming benefits and have been provided with further education on the correct claiming information process and have not been asked to repay any benefits.

(22) The effect of the Health Insurance (Dental Services) Determination 2007 is that benefits cannot be paid unless all requirements of the Determination are met.

In circumstances where the legislative requirements have not been met and MBS benefits should not have been paid, the department is legally obliged to pursue recovery of the incorrectly paid benefits in accordance with Section 47 of the Financial Management and Accountability Act 1997.

Certain initial examinations, x-rays and emergency services are excluded from recovery.

(23) The department has made no projections.

(24) The Department of Health and Ageing has advised that the government is aware of issues raised by stakeholders in regards to the Chronic Disease Dental Scheme.

(25) No, see response to question 22.

(26) Medicare commenced compliance activities in November 2008 (12 months after the commencement of the Chronic Disease Dental Scheme).

(27) See answers to questions 16 & 18.

(28) Dental services under the Chronic Disease Dental Scheme can only be legitimately claimed when they are provided in accordance with the Health Insurance (Dental Services) Determination 2007. Section 10 of this Determination requires that:

(2) An item in Schedule 1 (Dental Services and Fees) applies to a dental service included in the course of treatment only if, before beginning the course of treatment, the eligible dentist, eligible dental specialist or eligible dental prosthetist:

   (a) gave to the eligible patient, in writing:

       (i) a plan of the course of treatment; and

       (ii) a quotation for each dental service and each other service (if any) in the plan; and

   (b) gave a copy or written summary of the plan to the general practitioner

who referred the patient for dental services.

A claim for benefits under this Determination is only valid when the requirements of the Determination are met, this includes the provision of documentation as required by Section 10.

Preparing and sending paperwork after the course of treatment has commenced does not make claims under the Determination compliant. Failure by dental practitioners to provide the documentation prior to commencing the course of treatment denies the patient the opportunity to give informed financial consent in relation to how their entitlements are to be used; does not assist the patient to understand the treatment that is proposed; and restricts their options to seek clarification or a second opinion.

Failure to provide a copy or a summary of the treatment plan to the referring general practitioner (GP) reduces the capacity of the GP to provide effective coordinated care of the patient's chronic health condition.

The department takes a flexible approach when conducting audits of dental practitioners. Where all other requirements of the scheme are met, and the required documents are provided to the referring GP during, or soon after the course of treatment has been completed, the department may elect to provide further education to the dental practitioner and not seek recovery of incorrectly claimed benefits.

(29) Of the 739 complaints received by Medicare (as at 21 September 2011), no specific complaints have been identified from general practitioners relating to a failure of a dentist to provide a treatment plan to them.

(30) No.

Note: All figures are accurate as at 21 September 2011, unless stated otherwise