Medicare and the PSR - update and emerging issues

As stated in the presentation, regulation 6 of the Health Insurance (Professional Services Review Scheme) Regulations 2019 defines the standards for adequate and contemporaneous records, which provides:

“For the purposes of the definition of adequate and contemporaneous records in subsection 81(1) of the Act, the standards for a record of the rendering or initiation of services to a patient by a practitioner are that:

1. the record must include the name of the patient; and
2. the record must contain a separate entry for each attendance by the patient for a service; and
3. each separate entry for a service must
   1. include the date on which the service was rendered or initiated; and
   2. provide sufficient clinical information to explain the service; and
   3. be completed at the time, or as soon as practicable after, the service was rendered or initiated; and
4. the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record”.

Provided your letter contains all of the above information and is dictated at the time or as soon as practicable after the service was rendered or initiated, irrespective of when it is printed and placed in the patient record, you will meet these requirements

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. The principle was introduced in the context of General Practice. 80 services a day is seen as the upper limit of the number of consultations realistically possible in a normal GP working day. Medicare monitoring of GPs’ billings would identify any practitioners with such a profile who would then be reviewed.

There has always been the argument as to whether a staff specialist providing outpatient services could privately bill those patients under Medicare. There are agreements between Staff Specialists and the various State Governments that appear to allow this. There is no such agreement that I am aware of with the Federal Government but Medicare appears to be turning a blind eye to this. There is otherwise nothing new. Just as any other medical practitioner billing Medicare with a provider number allocated to them, YOU are responsible for those billings made against your provider number. It doesn’t matter who selects the item number billed. You need to ensure that in your agreement with the Hospital that the Hospital will be responsible for refunding any billings made by them using your provider number.

Yes. If the negotiated agreement or Committee Hearing results in repayment, a refund of fees of Medicare billings is required, irrespective of current or future practice status of the practitioner.

They look at the year 2 statistics, including billing amounts, as presented by Medicare when Medicare makes the referral to the PSR.

Section 86(2) of the Health Insurance Act 1973 (Cth) titled ‘Requests by Chief Executive Medicare to Director to review provision of services’ provides:

• “(2) The period specified in the request must fall within the 2 year period immediately preceding the request”.

You can bill patients whatever you want and irrespective of any Medicare rebate. Under your AHPRA Code of Conduct and at common law you do have a requirement to provide an informed consent, including an informed financial consent where there might be additional costs. In such cases, you must make them aware of the costs. Do not include any Medicare item numbers on such a private account unless the patient is eligible for a Medicare rebate for the service provided.

Theoretically it could apply to any practitioner, but in practice to my knowledge it has never happened.

I have gone through the explanatory notes of the July 2019 Medicare Benefits Schedule and cannot see a specific reference to this. It does not appear to be excluded under the excluded items list. However, as mentioned in the talk, MIPS cannot give a ruling that binds Medicare. If you have any doubt, then you must contact Medicare direct

Such cases can be referred to the Commonwealth Police for their assessment and action.