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Are you engaging in inappropriate practice? Professional Services Review Annual Report notes increase in requests to investigate cases

Newsflash 14 December 2016

The Professional Services Review (PSR) released its Annual Report in October 2016 which noted a substantial increase in the number of requests the PSR received from the Chief Executive Medicare to investigate cases of practitioners alleged to have engaged in inappropriate practice. 

The PSR received 80 requests from Medicare in the 2015 / 2016 financial year, which was an increase of 29% compared to the previous financial year and 82% higher than the 2013 / 2014 financial year. As at 30 June 2016, the PSR had 88 cases open in comparison to 57 cases at the same time the previous year. 

Inappropriate Practice

The PSR’s investigation of alleged cases of inappropriate practice aligns with its purpose to ensure that Commonwealth-funded services delivered by practitioners are clinically relevant and that payments are made in accordance with the Medicare Benefits Scheme (‘MBS’) and the Pharmaceutical Benefits Scheme (PBS).         

A practitioner is considered to engage in inappropriate practice, pursuant to section 82 of the Health Insurance Act 1973 (the Act), if the practitioner’s conduct in connection with rendering or initiating services is such that a committee could reasonably conclude that the conduct would be unacceptable to the general body of general practitioners or specialists in that specialty. 

The PSR’s Annual Report noted recurrent concerns during the 2015 / 2016 financial year including practitioners rendering a high number of services and a lack of understanding regarding the requirements relevant to the provision of urgent after-hours services and the rendering of Chronic Disease Management (CDM) items.           

Provision of Services

In 2015 / 2016, five matters were referred to the PSR relating to practitioners who, on each of 20 days in the previous year, billed Medicare for at least 80 MBS attendance items. This is referred to as the 80 / 20 rule and, if a practitioner engages in this conduct it is deemed to constitute inappropriate practice.  
   
The PSR noted that general practitioners who were referred to the PSR under the 80 / 20 rule offered a number of explanations for their high provision of services including that they work long hours, and they are familiar with their patients and can therefore attend to them efficiently. Further, many general practitioners were often unaware that 80 is the number of attendance items claimed as opposed to the number of patients the practitioner has consulted.   

General practitioners may be referred to the PSR for practice which does not breach the 80 / 20 rule. In the 2015 / 2016 financial year, 15 medical practitioners who exceeded 60 professional attendances on more than 100 days during their respective review period were referred to the PSR.  

Urgent after-hours services

A number of practitioners were referred to the PSR regarding concerns about their provision of urgent after-hours services, that is, MBS Item Numbers 597, 598, 599 and 600. 

Whilst the PSR found that practitioners generally met the time requirements for urgent after-hours services, the Annual Report expressed concern about practitioners’ interpretation of ‘urgent medical treatment’ as outlined in the item descriptor requirements for these items.  

The PSR’s review of practitioners’ clinical records noted that some practitioners had billed these items for conditions which would not constitute urgent medical treatment such as an uncomplicated rash and reissuing prescriptions for patients’ regular medication.       

CDM Items

The PSR found that an increasing number of practitioners were rendering CDM items, that is, MBS Item Numbers 721 to 732 and utilising computer generated templates which on some occasions resulted in Team Care Arrangements having minimal content specific to the patient for whom the plan was prepared.                  

The PSR found that in many cases practitioners were preparing GP Management Plans every twelve months and reviewing them every three months without completing any patient consultations and / or failing to review or remake the plan.                   

Outcome

Of the 49 cases completed by the PSR during the 2015 / 2016 financial year, the PSR Director determined to take no further action in 24 cases.  

If the PSR Director comes to the view that a practitioner has engaged in inappropriate practice, the PSR Director and the practitioner may enter into a negotiated agreement pursuant to section 92 of the Act. 

The negotiated agreement must include acknowledgement by the practitioner that they have engaged in inappropriate practice and may also include specified action such as a reprimand, repayment of Medicare benefits and total or partial disqualification from participating in the MBS or PBS for a period of time.   

The PSR’s Annual Report noted that, in the 2015 / 2016 financial year, the PSR completed 49 cases with negotiated agreements being ratified by the Determining Authority in 18 of these cases. Of the negotiated agreements which were ratified, repayment orders were made totalling $1,630,000 in 17 cases and partial disqualification was ordered in 12 cases.  

If a section 92 Agreement is not entered into by the PSR Director and practitioner, pursuant to section 93(1) of the Act, the PSR Director may establish a PSR committee and refer a person under review to the committee for investigation. It is noteworthy that, of the 12 cases that were referred by the PSR Director to a committee of peers in the 2015 / 2016 financial year, no cases resulted in a finding that the practitioner had not engaged in inappropriate practice.    

Conclusion

In an attempt to avoid engaging in inappropriate practice, practitioners are encouraged to:

  • Be mindful of the 80 / 20 rule and the number of professional attendances they render on a daily basis;  
  • Ensure their consultation records appropriately reflect the service provided including MBS Item Number descriptor requirements; and
  • Familiarise themselves with the MBS Item Number requirements for the services they render, particularly CDM items.  

Further, practitioners cannot be complacent as, even if they have previously been the subject of a referral by Medicare to the PSR, they may be referred to the PSR again in the future.  


Dominique Egan, Partner
Sydney

Patricia Marinovic, Solicitor
Sydney

Newsflash 14 December 2016
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