News

---

Navigating Medicare and the PSR

---

With the Medicare billing process often labelled as complex, confusing, and unnavigable, many GPs struggle to find the correct billing information.
 
To provide a refresher on navigating the system, as well as the Professional Service Review’s (PSR) referral process, representatives from the Department of Health and Aged Care (DoHAC) and the regulatory body hosted a session at the RACGP Practice Owners Conference last week.
 
Followed by a well-received audience Q&A facilitated by PSR legal advisor Margaret Parker, the session also covered the Philip Review of Medicare integrity and compliance, outlining the challenges of the Medicare system and recommended reforms.
 
Medicare rules and compliance
David Nott, who leads compliance education and engagement with the DoHAC, opened the session with an overview of the Medicare compliance process and current activities.
 
‘While we [the DoHAC] might use multiple compliance treatments for a given compliance risk, all compliance activities are thoroughly reviewed and evaluated,’ he said.
 
‘Ensuring correct claiming of Medicare is a responsibility of both the provider and any person who manages their billing and claiming.’
 
Administrative errors are often cited as a reason for incorrect claiming of MBS items, Mr Nott pointed out, before sharing example slides and tips for compliant Medicare billing. He advised GPs to:

• provide only clinically relevant services, referrals and access to medicines that are necessary for the appropriate treatment of the patient
• ensure only eligible services or benefits are claimed
• create and retain contemporaneous clinical and administrative records
• retain oversight of registration, approvals, billing and claiming, and remediation of any errors
• proactively educate themselves on the rules and requirements using the range of DoHAC and Services Australia resources, and contact these organisations if claiming errors are discovered.

Mr Nott also gave an overview of the process when DoHAC’s Medicare Compliance Unit refers someone to the PSR.
 
‘High volumes by themselves will not necessarily get you referred to the PSR,’ he said.
 
‘We do look for unusual claiming – claiming outside the norm, claiming a certain item at a high level. If it’s appropriate for your clinical practice and if the services are distinct and if the records are kept, and it’s all done correctly, that’s fine.
 
‘But, you might get a question from us after the data has been extracted and we’ve looked at the percentiles and the information.
 
‘You may come back and say, “Well, my practice is structured in this way. I see a lot of socioeconomically disadvantaged people, I work in a rural or remote area, or specialise in this particular area within the MBS,”, so we then have an answer.’

Mr Nott emphasised the importance of accurate and well-maintained records to ensure proper medical service provision, following clinical practice guidelines, and to be prepared to explain atypical patient volumes or practice structures, if questioned.
 
‘The important thing to know is services do need to be distinct from one another. The concept of a complete medical service is not known to everyone, but it’s an important one,’ he said.
 
‘Every service needs to stand out by itself as, “I do the activity I provided to the patient”, so all the time I spend on an ECG and then claim item 23, that should be separate time that I’m spending with the patient.
 
‘All item requirements – including all minimum time and content requirements – need to be independently met before claiming each service.’
 
Examples given were the time spent in carrying out a service which is covered by another item in the MBS, such as an ECG or skin biopsy, that may not be included in the consultation time. Or, each service for a chronic disease management (CDM) plan must be clinically relevant for each individual patient to attract a Medicare benefit.
 
‘Only time personally spent consulting with the patient can be counted towards the minimum time requirement,’ Mr Nott said.
 
Associate Professor Antonio Di Dio, former PSR Acting Director, gives an overview of the process at a recent presentation at the RACGP Practice Owners Conference, alongside David Nott from the Department of Health and Aged Care.

The PSR process
During the session, GP and former PSR Acting Director, Associate Professor Antonio Di Dio, tried to give attendees a sense of perspective regarding the chances of receiving a referral.
 
‘If you take a big snapshot: 160,000 people bill Medicare every day, about 100,000 are doctors, about 1000 get reviewed by Medicare, and about 100–150 get referred by Medicare to the PSR,’ he said.
 
‘Practitioners come to the attention of the Chief Executive of Medicare then have a series of delegates who are all medical officers, then if they can’t decide on behavioural change, they refer to the PSR.’
 
Between 2021–23, standard GP consultations and CDM services took the lion’s share of the most reviewed item numbers by the PSR, with items 23 and 723 retaining the top two spots. From April 2022 to March 2024, 150 GPs were referred to the PSR.
 
A GP is referred to the PSR due to inappropriate practice, Associate Professor Di Dio said, because of inadequate medical records, insufficient details on attendance time for items with minimum time components, prescribing, ordering of imaging or billing of item numbers.
 
Once the PSR director decides on which item numbers to review, the next stage is the committee review which, he says, is important to note comprises of peers.
 
‘If you’re a physio, the reviewers will be physios, and the committee will have physios on it. If you’re a GP, they’re going to be GPs,’ he said.
 
‘Any process with the PSR will be based upon a definition of inappropriate practice. A GP engages in inappropriate practice if the totality of their conduct in connection with rendering or initiating a service would be unacceptable to the general body of GPs.
 
‘So when a consultant reviews notes and these notes are randomly selected, there’s no checking for “best or worst” – it’s conduct in connection.’
 
Reasons for inappropriate practice relating to CDM items, include:

• ‘generic goals’ or no individualisation of the template to the patient
• a lack of qualifying chronic disease
• identical plans over time
• no consultation for team care arrangements.

For prescribing, examples of inappropriate practice included:
 

• prescribing a high ratio of second- to first-line antibiotics, and antibiotics without the record establishing a clinical indication
• long-term prescribing of opioids and/or benzodiazepines without assessing the patient, reference to pain specialists, and any clear management plan.

‘If the GP wrote lots of notes and did an examination and it looked like they took 40 minutes, but they prescribed 160 mg of OxyContin which they also prescribed the day before, which they’ve also prescribed the week before three times, then yes there was 40 minutes, but the prescribing was conduct in connection,’ Associate Professor Di Dio said.
 
In his role as PSR Acting Director, Associate Professor Di Dio made a pledge to improve PSR processes to ensure GPs being investigated are listened to and understood, and ensure their wellbeing is prioritised.
 
He said the Practice Owners Conference presentation aimed to help further alleviate any fear of being reviewed and provide further transparency and understanding on the processes.
 
‘I don’t want any of my fellow doctors who practice every week to live in unnecessary fear, and I especially don’t want any of them to underbill for all the incredibly hard work they do.
 
‘And the best way to prevent that is through education.’
 
Log in below to join the conversation.

---

---

compliance inappropriate practice MBS items Medicare Practice Owners Conference Professional Services Review PSR

---