In January and February alone, the PSR ordered various practitioners to repay more than $3 million.
Doctors hauled before the Professional Services Review for providing more than 80 consults per day have famously few avenues for reprieve – but the Department of Health, Disability and Ageing has now outlined the two scenarios which count as “exceptional circumstances”.
Under what is known as the prescribed pattern of services rule, Medicare refers practitioners to the PSR if they have billed the MBS for 80 or more services per day on at least 20 days within a 12-month period, or if they have billed the MBS for 30 or more telephone telehealth services per day on at least 20 days within a 12-month period.
The PSR can then order the provider to repay some or all of the Medicare rebates billed over these dates.
According to a DoHDA-issued fact sheet, which was updated on Tuesday, there is no actual legislative barrier to a practitioner providing more than 80 services in a day, provided that each service is clinically relevant, medically necessary and provided in an appropriate manner.
“However, we note that providing services at this level would place considerable strain on practitioners,” the document reads.
“Additionally, it might raise questions as to the quality of care the practitioner could provide, and the impact on the welfare of that practitioner.”
According to the document, unless a practitioner can prove that there were exceptional circumstances, the 80/20 or 30/20 patterns of service are considered inappropriate practice.
The two broad categories which constitute exceptional circumstances are: an unusual occurrence causing an unusual level of need on that day and an absence on that day of other medical services for the practitioner’s patients, with regard to the location of the practice and the characteristics of the patients.
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The Medical Republic understands, for instance, that some of the doctors running respiratory clinics during the pandemic were able to successfully argue that exceptional circumstances existed.
One GP has already been tripped up by the 80/20 rule so far this year, according to the PSR case outcomes for January and February.
The doctor, who entered a section 92 agreement with the PSR, agreed to repay $380,000, be disqualified from billing certain items and be reprimanded by the scheme’s associate director.
In total, the repayments ordered over January and February totalled $3,005,000, with the bulk resulting from committee determinations rather than section 92 agreements.
Of the five committee final determinations which came into effect in January and February, three were in relation to general practitioners.
In all three cases, the GPs were found to have kept inadequate notes and to have produced highly templated care plans with limited individualisation.
They were ordered to repay $400,000, $580,000 and $575,000, respectively.
