DoHAC mails docs on the brink of PSR referral

3 minute read

For the first time, the Department of Health is warning doctors who are close to breaking the prescribed pattern of services rule.

Letters from the Department of Health and Aged Care are going out to 146 lucky* GPs at risk of being referred to the Professional Services Review for inappropriate practice.

The focus of this latest lighter-touch compliance campaign, according to newsGP, is the prescribed pattern of practice rule, better known as the 80/20 rule.

“This is an opportunity for you to review your servicing levels before concerns are escalated,” the letter reportedly reads.

“While there are no legislative constraints for providing more than 80 services in a day, it is important to ensure that each service is clinically relevant, medically necessary and provided in an appropriate manner.”

Although it is technically true that there is no firm, legislated cap on the number of services that can be billed per day, the laws that are in place make it clear that billing for more than 80 services in one day is likely to put a doctor in hot water.

Under part 2(8) of the Health Insurance (Professional Services Review Scheme) Regulations 2019, “prescribed pattern of services” is defined a medical practitioner rendering 80 or more services in one day on 20 occasions or more than 30 telephone services in one day on 20 occasions in a 12-month period.

It’s unclear whether warning letters will also be provided to doctors in danger of breaching the 30/20 telehealth rule.

Exceeding this limit is automatically deemed inappropriate practice, except in exceptional circumstances.

If DoHAC becomes aware of a practitioner breaking prescribed pattern of service – and it does routinely monitor Medicare claims – it is required under subsection 86(1A) of the Health Insurance Act 1973 to refer that person to the director of the PSR.

While the Department notes that a referral to the PSR is “not a final or determinative decision regarding whether inappropriate practice has occurred” and there are a number of steps along the way, the PSR has only delivered one report finding no inappropriate practice in the last three years.

Update 18/10/23: PSR counsel Bruce Topperwien has advised that the PSR director has dismissed four cases relating to the 80/20 rule this year before they reached the committee report stage.

DoHAC-run compliance campaigns have typically come in the form of “nudge” letters that direct doctors to reflect on whether a certain billing practice is clinically necessary.

The 80/20 letters are slightly different in that doctors are being warned that they are nearing the threshold of breaking a very black-and-white rule where there is an easy way to course-correct.

“Normally with the 80/20 rule, it’s basically [that] you’re told when you’ve reached it and you’re not counselled, you go straight to the PSR, do not pass go, do not collect $200,” RACGP vice president Dr Bruce Willett told The Medical Republic.

“This is a new approach, to actually warn people that they’re approaching that 80-20 rule [threshold].”

It signals part of the wider shift in the PSR, Dr Willett said, toward a more educational – rather than punitive – role.

Most issues, he said, tend to arise because of the enormous complexity of Medicare rather than deliberate law-breaking.

Examples of exceptional circumstances for the 80/20 rule include an “unusual occurrence causing an unusual level of need” or a temporary absence of other medical services for that practitioner’s patients, either due to the location of the practice or the characteristics of a patient.

As recently as July, a GP pulled up for breaking the 80/20 rule successfully argued that there had been exceptional circumstances on each of the days and made an agreement to be counselled by the PSR director on inadequate note-taking and prescribing.

They did not have to repay any Medicare benefits.

*Well, it could be worse.

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