MINI\! It) 01
HEALTH
133 Molesworth Street
PO Box 5013
Wellington 6140
New Zealand
T +64 4 496 2000
11 March 2021
Theresa McLean
By email: fyi-request-14 7 [email address]
Ref:
H202101850
Dear Theresa McLean
Response to your request for official information
Thank you for your request under the Official Information Act 1982 (the Act) on 23 February
2021 for information regarding audit protocol for Primary Health Organisations (PHOs).
Information in response to each part of your request is as follows.
1. How many random enrolment audits have been carried out over the past 5
years?
Between 1 January 2016 and 23 February 2021, 280 providers have been audited for 'issues
based audits' and 47 providers have been routinely selected for programmed audits.
2.
What is the largest ($NZD) financial clawback a
DHB has claimed back following an
enrolment audit?
The largest ordered district health board (DHB) recovery during this period was $124,805.87
(excl GST).
3. What is the usual sample size of enrolled patients, which is then extrapolated across
the practice? Is there a
method for determining this sample size?
4. Are the findings of an enrolment audit at a
single practice sometimes extrapolated to all
practices within that PHO?
5.
Are practices given time to remedy the random audit findings?
6. How much notice are practices given before an random audit of enrolments?
Please refer to the
PHO Audit Protocol Financial, claiming and referred service (the Audit
Protocol), the PHO Service Agreement and the referenced documents incorporated for
information in response to these parts of your request. It is available at the following address:
https :/ /tas. health. nz/ assets/Prima ry-psaap-u 14/PHO-Aud it-Protocol-Financial-Claiming-
Ref erred-Service-V3. 1-pdf. pdf.
The audits are generally called a 'routine' audit in the Audit Protocol. Page 3 of the Audit
Protocol describes routine audits as either programmed audits or issues-based 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. This would be the closest to the 'random'
audit you refer to.
• 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).
7.
If possible, can you provide a
summary of the most common reasons for enrolments
being assessed as non-compliant?
Listed below are the most common reasons for enrolments being assessed as non-compliant:
• No signed enrolment form (ie, no valid evidence of enrolment):
tas. health. nz/assets/Pri ma ry-psaap-u 14/En raiment-Reg u irements-for-Contracted
Providers-a nd-PH Os-Version-4 .1. pdf. Please refer to Appendix 4: Sample Enrolment
Form
• Person not eligible or entitled to be enrolled (eg, person does not hold a resident visa)
• No auditable contact between patient and practice for 3 years (eg, $0 invoice incorrectly
updated contact date in the practice management system).
I trust this information fulfils your request. Under section 28(3) of the Act you have the right to
ask the Ombudsman to review any decisions made under this request. The Ombudsman may
be contacted by email at: [email address] or by calling 0800 802 602.
Please note that this response, with your personal details removed, may be published on the
Ministry website at: www.health.govt.nz/about-ministry/information-releases/responses-official
information-act-reguests.
Yours sincerely
Celia Wellington
Deputy Director-General
Corporate Services
Page 2 of2
