New campaign targets GPs at risk of breaching Medicare billing rules

Doug Hendrie

24/10/2018 3:26:14 PM

A new Department of Health campaign will send letters sent to hundreds of GPs over concerns about their billing practices.

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The 80/20 rule refers to practitioners who bill Medicare for more than 80 services a day for 20 or more days over the course of a single year.

Around 550 GPs and 70 practice managers across the country will be sent a letter with information regarding Medicare’s Prescribed Pattern of Services compliance rules, known as the ‘80/20 rule’.
The campaign comes as Australia’s Medicare watchdog, the Professional Services Review, deals with a 60% spike in the number of health professionals whose billing practices require review.
The letter begins ‘Do you know how many services you are claiming?’ and gives information about the 80/20 rule.
‘The 80/20 rule is based on the number of professional attendances per day, which may not be the same as the number of patients seen in a day,’ the letter reads.
The letter states GPs should monitor the number of daily professional attendances and ensure all items billed under their Medicare provider number align with Medicare Benefits Schedule (MBS) requirements.
Under these rules, if a GP or other medical professional bills Medicare for more than 80 services a day for 20 or more days over the course of a single year, they will be deemed to have engaged in inappropriate practice for billing at rates considered too high.
GPs exceeding this level of billing have to undertake the Practitioner Review Program, which can involve an interview and review of Medicare billing, with a possible referral to the Professional Services Review statutory process.
The 550 GPs who will receive the letter represent the 1.5% of Australian GPs most at risk of breaching the 80/20 rules.
The letter is the latest instance of the Department of Health’s (DoH) use of nudge theory techniques, in which tailored letters are sent to encourage specific outcomes.
The DoH sent a letter to almost 5000 GPs earlier this year regarding their high rate of opioid prescribing. The RACGP expressed concerns about how this campaign was targeted.
In 2017–18, the Chief Executive of Medicare sent 109 requests for review to the Professional Services Review, a 60% jump over the long-term average. Many of these were related to urgent after-hours billing. These requests represent the cases that cannot be resolved or explained after internal investigation by the DoH.
In the same period, 49 health professionals were ordered to repay overbilled amounts, according to the Professional Services Review annual report. More than half of these were for amounts of $200,000 and above, with the highest amount $2 million. Twelve of these professionals were partially disqualified, with two fully disqualified.
The most recent Professional Services Review case involved a GP who was forced to repay $123,000 and banned from billing for certain Medicare items for a year or more.

80/20 rule MBS items medicare medicare rebates


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