Updates from the Professional Services Review (PSR) Annual Report 2020-2021
The PSR operates independently as an agency within the Commonwealth Department of Health. The PSR safeguards the integrity of Medicare and the Pharmaceutical Benefits Scheme and is chiefly concerned with inappropriate billing practices.
The PSR reviewed fewer cases in 2021 than in 2020, 73 compared to the average of 99 per annum over the last five years but still ordered repayments of $21.2M, only a few hundred thousand dollars less than the year before. Repayments ranged from $10,000 up to $1.5M and over half the cases were of amounts greater than $200,000.
In addition to repayment orders or other actions, the PSR referred nine healthcare practitioners to a regulatory body for possible patient safety concerns and 22 were referred for concerns over major non-compliance with professional standards.
A major focus of the PSR was in relation to telehealth. It identified “billing Medicare for text messages, a lack of clinical input, inadequate documentation, failing to meet item descriptors and lack of clinical indication for service” as key issues.
Some cases that were billed were deemed by the PSR peer reviewers to be administrative and non-medical. These were for tasks that could be performed by administrative staff, such as ringing patients to ask them to present for appointments for test results or immunisations. Billing for sending a patient a text message was also considered to be a concern for the peer reviewer.
Prescribing remained a focus with a number of practitioners reviewed in relation to prescribing of second line antibiotics, some schedule 4 medication such as benzodiazepines and schedule 8 medications.
The PSR has identified a new area of concern relating to prescribing via telehealth using instant prescriptions. This is an emerging area of concern and will no doubt be a focus for the PSR moving forward. There were cases of doctors issuing medications that usually required a detailed history after only brief interactions and a series of text messages. In one case a doctor who was not in Australia issued prescriptions.
General Practitioner Reviews continue to make up the majority of referrals to the PSR (55% of the total of 73 referrals). These were focused on level B, C and D consultations both during normal hours, as after-hours consultations and via telehealth. Chronic disease management items, health assessments, ordering pathology and prescribing were also a focus.
Radiological services were identified by the Department of Health in the last financial year resulting in referral of a small number of radiologists to the PSR. The main concerns for these doctors was billing item 104 and the co-billing of MRI items.
The PSR also reviewed some activities of dental practitioners relating to the Child Dental Benefits Schedule
MIPS’ policy covers member assistance with all aspects of Medicare scrutiny ranging from targeted compliance letters, audits, Practitioner Review Program investigations and referral to the PSR.
MIPS’ Indemnity Insurance Policy does not cover you making repayments to Medicare, which is your responsibility.
When billing under Medicare it is important to remember that you are responsible for any billings under your provider number.
Services billed to Medicare must be in keeping with the specific item descriptors and
- not be an excluded service
- have been medically necessary
- show evidence in the notes of sufficient medical input
- demonstrate notes that are contemporaneous and adequate
- show evidence of notes and demonstrate that the conditions of the item number were met.
Please contact MIPS if you have any concerns with any contact you have with Medicare, our clinco-legal advisers are available to assist you.
See full version of the PSR report for 2020-21
This information is not intended to be legal advice and as such should not be relied on as a substitute. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Should you wish to obtain further information you can review our Member Handbook Combined PDS and FSG or contact MIPS on 1800 061 113. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Information is current as at the date published.
