Enrolment Audits - What you might have missed

Enrolment audits can sometimes feel mythical - you've heard of them, you've heard horror stories, but you've never actually heard of someone you know being audited.

We wanted to clarify what enrolment audits entail, and how often they happen. This is what we found out:

Firstly, there are two types of audits

• Programmed Audits are where the PHO is selected as part of a regular audit programme as decided by the relevant DHB or its agent. These are the 'random' audits often talked about.

• Issues-based Audits (also known as Selected Audits) are where the contracted health provider, or the PHO, has been selected for audit for a particular reason (such as unusual claiming patterns, or other matters that need to be clarified).

Since the 1st of January 2016, 280 providers have been audited for issues based audits. In that time, 47 providers have also been routinely selected for programmed (random) audits.

Here are some aspects of random audits that you should know:

  • You don't get much time! If you're going to be randomly audited, you'll get a minimum of 20 working days notice to get your documents in order, and be ready for a site visit. This means you can't ensure all your enrolments are compliant at the last minute, and track down patients with non-auditable contact for the last three years to re-enrol them.

  • Extrapolation - the auditors look at a sample size of enrolments, which is based off your practice's size, and then extrapolate the findings. This means that when figuring out what you need to pay back, the equation used is: $ value of invalid enrolments / sample size population = claw back

  • In this 5 year period, the largest financial clawback a DHB has claimed is $124,805.87. That's a lot of money!

The three most common reasons for enrolments being assessed as non-compliant were:

  1. No signed enrolment form
  2. Person not eligible or entitled
  3. No auditable contact for the past three years (Not re-enrolled)

Rapid Rēhita addresses all of these avoidable issues.

  1. The completed enrolment form is sent straight to your practice's email inbox - this saves you having to chase down paper forms. The online enrolment platform has must complete fields for the minimum data set required for an enrolment form to be valid. This means you won't be penalised for a patient forgetting to tick a box, or sign their name.

  2. Eligibility and Entitlement - Patients can't complete a form without declaring why there are eligible and entitled to enrol. In addition to this, documentation like visas can be uploaded alongside the enrolment form, by the patient. This means the practice is able to access the patient's proof of eligibility easily.

  3. Re-enrolments - easily solved by sending a bulk text to all patients who haven't been seen in the last 3 years. In the text, include a link to your practice online enrolment form, which includes a re-enrolment option. This gives the patient (and the practice) a change to update contact and eligibility details, and get re-enrolled with a new enrolment form being sent to the practice's inbox.

About Rapid Rēhita

Rapid Rēhita provide technological services to New Zealand general practices, especially by helping with online enrolments.

This is a blog about interesting information we've discovered along the way.

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