Enrolment Eligibility and Entitlement Expectations (That you might have missed!)
It's common knowledge that enrolment with primary care is important for getting capitation funding and helping patients access cheaper and continuous quality care.
Enrolments are also important for practices wanting to avoid having to pay large sums back to their DHB, when random audits by the Ministry of Health find enrolments that aren't quite right. This is known as 'clawback', and is when DHBs claim back capitation funding for ineligible/invalid patients. The auditors will check a sample of the practice, and then extrapolate their findings across the whole practice.
Below is a quick explanation of some crucial terms, plus a few other tips to make sure your enrolments are compliant. One important thing to note is that auditors may classify enrolments as 'invalid', or ineligible; this is explained below.
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A valid enrolment has:
- the minimum data set requirements
- a signature + date of signing (this date needs to be recorded in the PMS)
- or, for minors, and those unable to sign, a recognised guardian signing on their behalf
Rapid Rēhita's software won't let a non-valid form that's missing these fields slip through the cracks.
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An enrolled patient is eligible when they are a NZ citizen, have a work visa, or are for some other reason eligible to receive funded primary care in New Zealand. Some people may only need to prove their eligibility once, while others may need their eligibility periodically assessed. It's up to you to make sure you keep checking patient eligibility while they are enrolled.
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A patient is entitled to enrol if they are:
- Planning on using the general practice as their regular, ongoing provider
- Intending to be living in Aotearoa long term (more than 183 days over the next 12 months)
- Not receiving continuous care through another agency, like the Department of Corrections, or the Defence Force.
Our form confirms this, but if your patients have a change in circumstance, it's up to you to update your PMS, and thus the NES!
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If a patient mentions that they're heading overseas for 12 or more months, you must un-enrol the patient. The patient isn't residing permanently in New Zealand, and is not eligible, so you need to un-enrol them after their final visit. (And make a note of why you've un-enroled them in the PMS!)
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The NES is considered 'the single source of truth' (in the MoH's words). This means it's really important to check that what's on the NES is the same as what's on your PMS to avoid discrepancies cropping up. This includes making sure the date of enrolment on the PMS isn't the date you enter the form, but the day it was signed.
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It is considered best practice to confirm a person's identity with photo ID, or other documents when they're presenting in person for the first time. However, this is not compulsory. It's the same with confirming eligibility documents exist. In some practices, paying for things like a birth certificate is not always possible for patients. The MoH acknowledges this, and people can enrol without documents, if the practice is confident they are eligible.
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The enrolment process is considered incomplete until the patient has been provided with information about how their health information is used. (For Rapid Rēhita, patients are required to tick that they've read and received this information, but a surprising number of practices forget to give out this information!)
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If a baby is pre-enrolled, they still need a proper enrolment form completed. Best practice is described as: getting in touch with the family within a week of receiving the NIR notification, welcoming them to the practice, and giving them an enrolment form. With Rapid Rēhita, it is as simple as texting them a link to enrol. This saves the family from having to come in before the newborn's 6 week check, and gets enrolling sorted without a hassle.
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Re-enrolments. Patients can be enrolled for up to three years, without having a consult. After this, they need 'confirmation' of enrolment. If a person isn't seen, or confirmed, they will expire in the NES. Confirmation (re-enrolment) can be done by
- Signing a confirmation of enrolment
- Signing a new enrolment form
- An email or phone call with the patient confirming that they want to stay enrolled.
We've found patients aren't always great at answering phone calls... Rapid Rēhita means you can email or text a new re-enrolment form to the patient. You are able to simultaneously confirm their enrolment, while making sure the details you have for the patient are current. It's quick, and makes life easier for you, and your patients.