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What is the story with DVA and EPC referrals for residents in aged care facilities?

I am servicing several aged care facilities and am finding the different in-house practises regarding billing interesting...

One facility has basically all its permanent residents on DVA or EPC referrals regardless of whether they are high care or low care

Another had this but when it was taken over by another organisation and changed from being shire-run to being privately run, the residents were reassessed resulting in most of their statuses being changed from being low care to high care. They then advised me to cease billing their high care residents' treatments to DVA/Medicare as their understanding is that high care residents are not eligible for treatment under DVA/Medicare

Another says their residents are ineligible for DVA/EPC referrals because they live in an aged care facility

The facility that has most of its residents' treatments being billed to DVA/Medicare fill out the paperwork (they produce the care plan) and give it to the GP who signs off on it. The GP does not seem to see the residents to check that their care plan is appropriate

The one that has ceased having their high care residents on DVA/EPC referrals was taking their residents to the GP for care plans to be done

So at the end of the day I'm confused about the following:-
1. are people in residential aged care facilities eligible for DVA/EPC referrals? Is it just low care residents that are eligible or are high care residents eligible too?
2. if they aren't and I get audited, will I have to repay the money to DVA/Medicare even though I had nothing to do with organising the referrals?
3. is it worth the headache of explaining to the residential aged care faility and or the GPs that what they are doing may not be correct/legal and risking them changing to another (less concerned) service provider?
4. if these residents aren't eligible, surely the practice nurses/practice manager/GP would be aware of that - what happens if and when they get audited? How far down the line will the audit tidal wave travel?
5. for those residents in state-run/managed facilities, should they have access to DVA/Medicare at all? Aren't DVA and Medicare federally-funded bodies? Is this state-run facilities palming off some of the costs they should be wearing onto the federal government?

Any thoughts/answers out there?

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I share all of your concerns. I was under the impression that high care residents were not eligible for DVA or EPC allied health referrals, but it's happening more and more.

I've got a friend who is being audited by medicare and has numerous irregularites due to the fact that the referrals wern't done properly. All the paperwork was managed by the facility, but she's the one who ultimately has to answer for it if it's not right!

I think the **** might hit the fan with this one. I'm pretty insistant with the ACFs that I go to that i'm not interested in seeing high care patient on EPC plans. Even though the bulk bill fee is higher than my current charge, i'm not interested in the drama if it goes wrong!

Phil

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Phil Marshman
Mackay, Queensland Australia

This is something that I was looking into earlier this year and I found this

http://www.health.gov.au/internet/ma...ment-qanda#6_4

To me, this would suggest that general treatments should not be covered for high care residents but fine for low care.

Is anyone aware if the APodC has clarified this?

The problem when 2 funding systems cross.
Thefunding formula for high care residents includes the cost of podiatry, so the aged care facility is responsible for providing the podiatry care, this is not included in the funding for low level care.

But, all individuals can chose to have their health care provided by who they like, and if the service is Medicare eligible, Medicare will rebate the individual. The individual can then assign this fee to the health practitioner.

So, in the first situation, you are providing podiatry services on behalf of the aged care facility, and in the second, in the same way you would in your rooms, as an agreement with the individual patient.

Remember, the Medicare payment goes to the patient, who can assign it to the practitioner, and the patient has the right to choose who provides their podiatry. They could visit another podiatrist down the road if they were able and wanted too, or even have a different pod visit the facility if they paid.

Yes, it is a form of cost shifting, from the facility to the Commonwealth, but as long as the paper work is all in order, not a breach of Medicare funding guidelines.

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Stephen Tucker
Calvary Health Care

My location

From DVA:

RESIDENTIAL AGED CARE FACILITIES (RACFs) ≠
The level of care (high or low) refers to the health status of the eligible veteran, not the facility in which they reside. All treatment provided to veterans receiving high level care, regardless of the level of facility in which they reside, requires prior financial authorisation from DVA.

HIGH CARE - RACF ≠
Prior financial authorisation is required to provide clinically necessary allied health services to eligible veterans in Residential Aged Care Facilities, who are receiving a HIGH LEVEL OF CARE. Authorisation will be given only in exceptional circumstances.

Just about to post the same thing. It clearly states this on your DVA billing codes. I have only just been given a list of High Care/ Low Care residents at a facility I have visited for the last 12 months & am baffled as to how they grade them, some Low cares have dementia & some High cares seem quite mobile & normal.
Not sure about the EPC thing, I do have one facility that has all px on EPCs, and won't pick up the tab for 1 extra visit a year when their 5 run out.
Definitely get a printout from the facility of all px & there care rating & refuse to see High care DVAs unless the facility is paying is all I can suggest.
Cheers,
Kara.

Kara,
If they are High Care residents, they could be in breach of their accreditation standards.
Each patient requires a care plan, including one for podiatry/foot care that is reviewed as part of the accreditation process. These care plans provide the evidence to support the level of care. The care plan should also indicate the level of podiatry care required, plus what the Resi care facility should be doing between visits.

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Stephen Tucker
Calvary Health Care

My location

Hi
My father resides in an aged care facility and have an on going issue with facility using EPC for allied health services that should be provided by facility. He needed to be assessed by a speech pathology because he had swallowing issues and facility would not provide a speech pathologist unless I allowed them to FAX the GP a EPC form to provide this service. I know this was a breach as I know that this service should be provided to high care residents at no cost and Medicare clearly states that EPC should not be routinely used for high care residents. AlsoEPC cannot be used without resident representative permission. In the end I had to report them to the aged department and they contacted them and ordered them to arrange for a speech pathologist. I was also informed by the aged care department that EPC is not needed as this service is provided to high care residents. High care residents can use the EPC for allied health services that is not already funded for high care residents. Unfortunately residents do not know the aged care law or the rights and assume that the only way that they can get allied health services is via EPC. The facilities are giving inaccurate info to residents and family. Unfortunately the facility is still using EPC for podiatry to cut my father's toenails without my permission. And what if the 5 per year run out, will they cut is nails, I was told they will. Have warned them about the implications if they keep on been dishonest. I have also read the replies to your enquiry and yes facilities can definitely be in trouble if audited. I have Medicare records and other evidence of the facility using EPC wrongly and will provide this to the aged care department in the future. I hope this info helps you as I have seen first hand how facilities abuse the system as my father resides in one.

I've decided that Medicare or departmental audits in aged care facilities can work wonders for both residents and allied health professionals...!

Medicare fraud reporting options can be found at this link:- http://www.humanservices.gov.au/cust...d-and-security

Complaints can be lodged anonymously via the web

Unfortunately this particular facility have not had a proper audit or they would have seen how it is misused. Thanks for the link to Medicare, I already have their details and will pass on my papers to them and the aged care department in the future. I just hope that making my situation known will make allied health workers aware of what aged care facilities are doing. Thanks for your reply