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Primary Health Organisations: passing the enrolment audit

GPs must take steps to ensure only eligible enrolments are made to the Primary Health Organisation register; invalid enrolments can prove costly when District Health Boards claw back the funding. Barrister Hanne Janes outlines ways for GPs to better pass the enrolment audit

MPS has received a number of requests for assistance from GP members following enrolment audits. It is clear there are two distinct areas of the enrolment system that are causing members difficulties: one relates to eligibility for enrolment, and the other concerns actual enrolment processes.

The issues relating to each practice’s audit is entirely fact-specific, so this article is a general commentary only.

Getting it right

Why should GPs be concerned about enrolment audits? Because for many, extrapolation of random audit findings across their entire Enrolment Register has proved very costly indeed when their District Health Board (DHB) seeks recovery.

Health providers are required by the Ministry of Health (Ministry) to take all reasonable steps to ensure that only eligible people are enrolled and included in the practice’s Primary Health Organisation (PHO) Enrolment Register. Currently, the Ministry, DHBs and PHOs are making a clear distinction between “invalid” enrolments (defined as no validly signed enrolment form at date of audit) and “ineligible” enrolments, in respect of whether extrapolation occurs or not.

Current and future policy

Importantly, GPs should be aware that the Ministry’s enrolment policy is regularly evolving, with input from DHBs, PHOs and providers. While it would be expected that a GP’s PHO would communicate changes in enrolment policy to them, it is nevertheless the GP’s responsibility to ensure they are aware of the current enrolment requirements and that their practice is compliant.

It is the GP’s responsibility to ensure they are aware of the current enrolment requirements and that their practice is compliant

A new Enrolment Requirements for Providers and Primary Health Organisations Version 3.1 was published on 9 July 2012. GPs are also responsible for assessing the eligibility of a person for publicly-funded services against the criteria set out in the Eligibility Direction 2011. These two documents set the standard, and are incorporated into the DHB-PHO contracts.

Via PHO-GP service or back-to-back agreements, members are also contractually obligated to comply. Both these “standards” documents are available on the Ministry’s website, as is the Primary Healthcare Audit Protocol (Audit Protocol).

GPs will be aware there was a moratorium (previously set out in Appendix 4 to the Audit Protocol) that applied to all audits conducted between 12 March 2010 and 28 February 2011. The purpose of the moratorium was to give PHOs and providers the opportunity to become fully compliant with enrolment requirements before they were due to submit their Enrolment Registers for the April-June 2011 period.

From 1 May 2011 to 30 April 2013 a quality improvement process applies (Quality Improvement Period). This is set out in the enrolment requirements document. GPs must be aware that after 28 February 2011, only one of the previous moratorium exception factors remained available: this relates to ineligible patients only. Ineligibility relates to whether a person is a New Zealand resident, holds valid resident visas or work visas, etc.

While it is the person’s responsibility to provide appropriate documentation evidencing eligibility, the GP practice is responsible for assessing the person’s eligibility, and they are expected to view and confirm the existence of relevant documentation to assess eligibility, and ideally take a copy and hold it with the person’s medical records.

Under section 300 of the Immigration Act 2009 (which came into effect in November 2010), the Ministry and DHBs have access to eligibility data for overseas travellers and immigrants to determine eligibility to access publicly-funded health services. Similar disclosure is available to health providers under section 301 of the Immigration Act 2009.

Assessing eligibility

Eligibility has to be determined at the point the patient is being enrolled, and when the services are actually being provided. If the person’s eligibility is unlikely to change (eg, New Zealand citizens and permanent residents), the GP may need to only assess eligibility once, but for individuals who qualify under other eligibility criteria, they will need to be periodically reassessed before services are provided.

There are also circumstances where even a New Zealand citizen, for example, may become ineligible to be enrolled, such as if they declare an intention to live overseas for 12 months or longer, or if there has been no entry in their medical records within the previous three years.

During the Quality Improvement Period, audit reports will continue to give advice on enrolled patients who are not eligible, and those individuals will be removed from the register, with no further capitation payments being made for them. Practices will not face extrapolation across the whole Enrolment Register for ineligible enrolments.

GPs reading the enrolment requirements need to be aware that while the words “invalid enrolments found in the sample” could initially be read more widely, taken in context they refer only to ineligible enrolments. This has been confirmed by the PHO Service Agreement Amendment Protocol Group (PSAAP).

Practices will not face extrapolation across the whole Enrolment Register for ineligible enrolments

Assessing validity

While eligibility is a prerequisite, it is not necessarily determinative of a patient being entitled to be enrolled – for example, the patient may live overseas and the general practice would not be their regular and ongoing primary healthcare provider. For purposes of valid enrolments, the person must be intending to live permanently in New Zealand for a period of two or more years.

Further, three years is the maximum period a person in New Zealand can be enrolled with a PHO without a first level service consultation being recorded, a new enrolment form signed, or auditable contact with the person that confirms continued enrolment.

For purposes of valid enrolments, the person must be intending to live permanently in New Zealand for a period of two or more years

Signing of enrolment forms became mandatory on 1 April 2004. Patients validly enrolled with a practice prior to that date – as long as there is at least one first level service consultation recorded in the medical records within each three-year period – were not required to be re-enrolled.

For an enrolment form to be considered valid on the day of audit a number of criteria must be met. It is beyond this article to outline all of these, but three that GPs should watch out for are:

  • The person’s enrolment details must comply with the mandatory minimum dataset, which is outlined in Appendix Two of the enrolment requirements document.
  • The person must sign the enrolment form. The date on which the enrolment form was actually signed must be the date that is recorded on the Enrolment Register. Some practices, whether due to administrative procedures or software design, record the enrolment date as the date it is entered on their patient management system. Such enrolments are audited as being invalid and extrapolation will apply.
  • If the person is a child under the age of 16 years, a parent or guardian must sign a separate enrolment form in the name of the infant; the child cannot be enrolled under the parent or guardian’s enrolment form. Once a dependent child reaches 16 years of age, a new enrolment form does not need to be signed if he/she remains with the same provider of first level services. The criterion of consulting the provider at least once in a three-year period or reconfirming enrolment applies.

The enrolment requirements document notes that in January/February 2013, PSAAP (or parties to the PHO agreements if PSAAP no longer exists) will review progress and any final requirements for the enrolment standards to be fully met. GPs are therefore recommended and encouraged to liaise with their PHO and/or check the Ministry’s website to ensure they are aware of any changes to enrolment and eligibility criteria.

It is likely that, from 1 May 2013, extrapolation across the member’s Enrolment Register will apply for both invalid and ineligible enrolments.

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