Questions raised over new crackdown on after-hours GP service

Doug Hendrie

3/10/2019 3:38:06 PM

A key health watchdog is investigating Australia’s largest after-hours GP service in the first ever inquiry into a company rather than individual doctors.

Doctor on home visit
After-hours doctors are popular – but there is new scrutiny of the sector.

In a move that could send shockwaves through the after-hours sector, the Federal Government’s Professional Services Review (PSR) – which usually focuses on individual healthcare practitioners – is investigating the National Home Doctor Service (NHDS), according to the ABC.
The PSR is reportedly investigating whether the service ‘knowingly, recklessly or negligently’ allowed some of its 800 doctors to engage in ‘inappropriate practice’.  
The claims centre on the use of ‘urgent’ after-hours Medicare Benefits Schedule (MBS) items, according to NHDS chief executive John Pappalardo.
The company – also known as 13SICK – denies the claims and has mounted a Federal Court challenge on the basis its doctors are contractors rather than employees.
‘We are confident that we have at all times met the expectations of the [PSR] and the governing legislation,’ Mr Papparlardo told the ABC.
The PSR’s move raises broader questions over its decision to investigate a company rather than individuals.
RACGP President Dr Harry Nespolon told newsGP that while he supports the PSR’s right to scrutinise improper billing, he has questions over the potential expansion of the agency’s role.
‘This is the first time that a corporation is being investigated,’ he said.
‘It is reported that some GPs have been caught up in the PSR process through no fault of their own due to the backroom activities of, especially, non-medical owners.
‘The outcome of this case will show us the extent and possibly the operation of these new laws.’
PSR executive officer and general counsel Bruce Topperwien told newsGP he could not comment on the specific case due to the pending legal action. But he did confirm that the case represents the first time the PSR has investigated a corporation rather than individual practitioners. 
‘The Health Insurance Act talks about persons, and “person”’ can also include a corporation,’ he said. 
Section 80 of the act states the PSR scheme is for ‘reviewing and investigating the provision of services by a person to determine whether the person has engaged in inappropriate practice’.
Mr Topperwien said the PSR only investigates matters referred to the agency by the Department of Health.
‘We have no role at all in what gets sent to us. That’s from the compliance area within the Department of Health,’ he said.
The investigation comes after the Government cracked down on the after-hours bulk-billing sector, restricting the use of urgent after-hours item numbers and changing rebates to reflect the level of qualification attained. 
The Government required doctors working for after-hours services to assess and record the details of any urgent service.
The definition of ‘urgent assessment’ was changed to cases where medical opinion is that the condition requires assessment that same night or other unbroken after-hours periods, and that assessment could not be delayed until the next in-hours period.
The use of urgent after-hours MBS items increased by 157% between 2010–11 and 2016–17, a phenomenon the Medicare Review Taskforce stated had ‘no clinical explanation’ in a 2018 Q&A document.
‘The growth had been driven by a corporate model of advertising on the basis of convenience, rather than urgent medical need,’ the document states.
However, the urgent after-hours arrangements did not change in rural and regional areas, in recognition of the existing difficulty Australians in those areas had in accessing after-hours care.
The RACGP supported the restrictions over concerns the popular bulk-billing services were often staffed by doctors who were not suitably qualified.
In a 2018 position statement, the RACGP argues that bulk-billed after-hour services should be restricted to GPs, general practice registrars with supervision, doctors working towards Fellowship, or doctors with more than 10 years’ experience.
Up to 100 doctors make agreements to repay rebates every year following a PSR investigation.

Correction: This article previoulsy stated the Government had ‘tightened’ the definition of urgent assessment.

after-hours bulk billing compliance Medicare

newsGP weekly poll What area of medicine do you find most difficult to stay across the changing clinical evidence?

newsGP weekly poll What area of medicine do you find most difficult to stay across the changing clinical evidence?



Login to comment

Dr Mohd Haris Mohd Noor   4/10/2019 11:26:04 AM

Disclaimer: I do not work with any after-hours medical deputising services, but do recognise their place in providing a useful service to the community.

Whilst it's important to bill correctly and ethically, this could drive doctors to become nervous about interpreting borderline cases of "urgent attendance" and potentiallly underbill. This will impact on the financial viability of such after-hours services. I have seen the after-hours home visit services in my local regional Victoria close down.

Let's have some context here. The urgent after-hours Medicare rebate is $131.90, whilst the urgent unsociable after-hours (between 2300 and 0700 hour) Medicare rebate is $155.45. Compare that to the average cost of a single ED presentation to the public hospital, which was $584 (based on the IHPA Australian Public Hospitals Cost Report 2013-2014 Round 18). If we can avoid unnecessary ED presentations, there is a great, non-trivial saving to the health system.

Dr Vinod Lal   4/10/2019 11:51:07 AM

PSR referral should have been done years back when MBS claim by afters hrs exceeded 150 million dollars.
First of all--Many doctors did claim excessive amount.This was augmented by companies whom they worked for. In fact both the company and doctors should be held responsible. Above all company should be liable to pay back and prosecuted because it is the company's responsibility as an facility provider under whom the business is registered or employer to make sure rules are followed.
There should be no mercy for rorters of tax payer dollars and they should be prosecuted as criminals because the intent is very clear--FRAUD FOR PERSONAL
RACGP should now lobby for doctors only to own and run medical centres.

Dr Colin Scott Masters   4/10/2019 9:38:29 PM

RACGP may want to lobby for better representation of individual GP's. The big companies as above go straight to federal court. GP's to spend hundreds of thousands, as below.

Dr Anchita Karmakar’s case against the Professional Services Review will go to trial, after a Federal Court judge rejected the government’s third attempt to have her claim struck out.
Late last month Justice Logan found the health minister and the PSR director had a case to answer and set aside three days from April 1 for a hearing, at which Dr Karmakar will be represented by a legal team led by Julian Burnside QC.
Julian burnside summarised the current state of affairs thus:
“It is hard to escape the conclusion that the PSR and AHPRA act like bullies: they know they will prevail because they have great powers,” he concluded. “They are worth opposing, because there is only one effective way to defeat a bully: stand up to them; resist them; do not let them get away with what they do.”

Dr Rodney Paul Jones   5/10/2019 10:26:12 AM

When will the bureaucrats learn?
Medicine is . and always was a 24/7/ business.
They pretend it isn't because they don't want to actually pay for it. An after hours consultation is only an emergency when its them

DS   12/10/2019 9:05:06 AM

It’s hard to believe that company was not aware of it. All the patient bookings and call outs are under practice managers and reception. Billings are also checked by reception/ other staff. If the incorrect billing took place then company surely knew about it.

On the other side, I believe it is not fair to call some of the consultations fraud (in general) in which billings were correct but investigators did not like the notes and call it inadequate and label it as a fraud. Investigators need to please understand that medical notes are done in a great hurry and are not as well decorated as nursing or allied health notes.

Dr Ilhaam Abdul Hameed   12/10/2019 9:55:10 AM

I think there should be a clear cut definition what do they mean by after hours urgent billing. Most of the patients they see are paediatric with viral URTI and gastroenteritis when you take this in the parents perspective this is actually an urgent illness for them if they did not have the option of calling this after hours services they will be invariably ended up in ED and waited for 4-5 hours to be seen, in this cases I would agree with Dr. Noor’s comment isn’t it better to spend 131.90 than 584 of tax payers dollars.. To be fair to those doctors they could possibly maximum see 2-2.5 patients an hour and the over head at least 50 dollars an hour and they get only 70% of the billing and pay the GST on top of that. If the doctor charges as non urgent bill he will get around 50 dollars is it worth the money for his effort?? Rather drive Uber, this is why I stopped working after done it for about 6 months as I could not convince myself to charge these consults as urgent consults.