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What to expect

Karo has prepared the following summary of what your PHO can expect when the MoH does its scheduled PHO audit of patient eligibilty and practice enrolment processes. It is based on the PHO Audit Protocol which is available on the MoH website: Primary Health Care Audit Protocol

 

Please note that this summary is NOT an official MoH document, and we do not accept any liability if the MoH audits you on any item that is not mentioned on this page.

Audit objective

The objective of the audit is to assess the eligibility and entitlement of the individuals listed on the PHO's enrolment register to be included in the calculation of the capitation funding paid to the PHO.

The audit also examines the enrolment processes in place at the PHO's member practices.

Scope

The audit is usually restricted to a single quarter. The objectives are to

  • assess the accuracy of the data included on the enrolment register
  • assess the eligibility of the people on the enrolment register
  • seek third party evidence of enrolment
  • assess compliance with the enrolment requirements for PHOs.

Components of an audit

An audit report has three sections as follows:

  • section 1 - PHO level
  • section 2 - enrolment processes at practice level
  • section 3 - detailed sampling at practice level

 

More detail on these sections of an audit report follows:

Section 1: Primary Health Organisation

1. Register summary: This is an examination of the PHO register and total number of patients submitted/accepted etc.

2. Registration after the organisation became a PHO: This checks for all patients who have a registration date after the organisation became a PHO but who are not enrolled. Note: there shouldn't be any!!

3. Unusual dates: This checks for a range of things including

  • people with a 'date last visit' before they were born or after they died
  • people with a 'date registered/enrolled' before they were born or after they died
  • too many people with the same enrolment date (where there isn't a valid explanation e.g., date shifted PMS)
  • too many people with the same 'date last visit' (as above).

4. Deceased people: This checks you have removed the people that Karo marked as deceased on the practice 'Update spreadsheet'.

5. Duplicated people: This checks that you have removed duplicates from your PHO. These people are listed on the update spreadsheet (sheet 8: duplicate NHI).

6. Ineligible person funded: This checks for 'Mickey Mouse' and family, and that people are New Zealand residents and don't have overseas addresses.

7. Community Services Cards: This checks whether you have more than one adult (over 18 years old) with the same CSC number (these people are listed on the update spreadsheet on sheet 9).

8. Enrolment register details: This checks how many people do not have a residential address. Note: the threshold for CBF is only 80% of the register.

9. Survey: A mail-out survey to 200 people to confirm they are enrolled with the PHO.

10. Not enrolled: If it is more than three years since your PHO was established, this checks that everyone in the practices who has been in the PHO for over three years is enrolled i.e., no one should still be registered after three years!

Section 2: Enrolment processes at practices selected for audit

1. Enrolment processes

The practice will need to outline their enrolment process and the MoH will confirm whether it is compliant with the contract, as follows:

(a) New enrollees

The national enrolment process occurs when a person:

  1. indicates to a provider that they intend to use that provider or PHO as their usual provider of essential primary care services
  2. is provided with information about the benefits and implications of enrolment
  3. is provided with information about where personal information is sent and how it is used
  4. agrees to provide details for inclusion on the enrolment register or confirms details already held
  5. agrees to the enrolment process by signing an enrolment form
  6. is given the opportunity to request a transfer of notes from their previous provider where a change of provider occurs.

 

(b) Dependents

  1. Authorised representatives and individuals can enrol dependents.
  2. In the case of a dependent child under 16 years, the process can be completed for them by a parent or caregiver who has custody.
  3. In the case of other dependants, the process can be completed for them by their authorised representatives.

 

2. Enrolment forms

The practice will have to provide a copy of their enrolment form and the MoH will confirm whether it is compliant with the contract.

The form includes seven points that the enrolling person agrees that he/she understands before signing it. They are:

  1. This provider is a member of a Primary Health Organisation. I have been informed of the implications of enrolment with a Primary Health Organisation and I intend to use this Primary Health Organisation as my usual provider of primary health care services.
  2. For funding purposes, the information on this form and contact information (i.e., the name of my provider and the date of my last visit), but not my health information, will be sent to the Ministry of Health.
  3. If I enrol with another Primary Health Organisation, my previous or 'old' Primary Health Organisation will be informed of this change. They will not be informed of the name of my new Primary Health Organisation.
  4. If I visit another provider, the Primary Health Organisation I am enrolled with will be informed of the date of this visit and my NHI number but it will not receive the provider's name and my health information in relation to this visit.
  5. The information I have provided on this form will be used by the Ministry of Health to give me a NHI number or update my NHI information.
  6. My health information, which will not include my name, may be sent to the Ministry of Health and may be used by District Health Boards to plan and fund future primary health care services.
  7. My primary health care provider may send my health information to other health professionals who are directly involved in my health care and treatment.

Section 3: Findings at selected practices

These findings are based on a closer examination of a statistically significant number of randomly selected patients.

1. Examination of records: The MoH will check enrolment status and view the enrolment form for each person who is enrolled.

2. Enrolment status: The MoH will check that everyone who was registered after the PHO start date is enrolled and, after three years in the PHO, that everyone is enrolled.

3. Date of enrolment: The date of enrolment needs to correspond with any enrolment or re-enrolment forms that the patient has signed, and only the enrolment date (not the registration date) should be updated.

4. Evidence of enrolment: The MoH will check the practice has a signed enrolment form for the patient. Scanned forms are acceptable but if there is any doubt about a form, the practice may need to produce the original form.

5. Date of last consultation: The MoH will check that a consultation actually took place on the date listed as the 'date last consultation'.

6. Ethnicity: The MoH will check that the ethnicity on the PMS matches the ethnicity on the enrolment form.