It’s highly likely the number of doctors caught in the PSR net will continue to increase. Here’s what not to do
While the incidence of MBS malfeasance by doctors appears to be on the increase – up 82% and 29% in the last two years respectively – the overall rate is miniscule. Specifically, the number of referrals for investigation by the Department of Health represent less than 0.1 of 1 per cent of the entire population of doctors in the country in this last financial year.
Out of this elite crew of 80 doctors (of which GPs make up about 75%) only seven were found by the Professional Services Review (PSR) committee to have practiced “inappropriately”. One of these doctors was made to repay a whopping $1.39 million to Medicare. Five ended up being referred to medical boards and other bodies for inappropriate practice so serious, it may have represented a threat to life.
Here’s five ways you can get on the radar for an audit that might land you in this year’s PSR review club.
1. Computer-generated chronic disease care templates
If you do a lot of CDM plans, they’d better be properly individualised and have a few fields in them that are directly relevant to the patient. A lot of the gang of 80 were pulled up for mass generating these plans – quite lucrative in MBS terms – from existing electronic patient records but with very little apparent direct overview of the patient in respect to an individualised plan.
In some instances, the PSR said it believed some patients had no idea they were even on a care plan, despite this being a clear requirement. One enterprising 2016 inductee to the PSR club had generated more than 600 management plans, 400 team-care arrangements and 1000 item 2713 mental-health assessments, an item that is supposed to have a minimum 20-minute consult time.
2. Ye olde 80/20 rule
This rule says if you do more than 80 items on any 20 days in a year, make sure you’ve got a really good excuse. The following excuses generally won’t be good enough:
• I know my patients so well I can see them in a few minutes each, some in even less
• My clinic boss is like that guy in the battle scene in Ben Hur whipping the slaves to row the boat faster
• What can I say, I’m a hard worker
• I swear there was a chicken flu alert
The PSR does acknowledge that, if well documented, some legitimate situations can push someone over the line, and you can actually break the rule and live to tell the tale.
But you really have to have your ducks in a row paperwork-wise. Reasons to be given leeway can, but don’t always, include:
• My practice has developed a highly efficient nurse based CDM processing system (hence the 80/20 violation)
• I have an “area of need” provider number and am locked into the practice and management demands I work long hours
3. Work in a large practice and assume they’ll look after everything
The PSR targets the practices of individual doctors, not of whole practices. So where a large practice, particularly a big corporate, might take on a doctor and appear to look after all their worries, they are not responsible for individual breaches of a doctor, no matter what KPIs they might be giving you.
In a couple of instances, doctors working for large corporate practices have been ordered to repay Medicare in full for a particular breach, but the practice owner is not required to pay anything – not even the 30-40% cut you may be giving them as a part of your deal – as they’re not technically responsible for the breach.
There is also some consternation over the amount of overseas trained doctors getting into trouble. They are usually working for a large practice and claim ignorance of the 80/20 rule. Which doesn’t get them out of trouble generally. Still, the PSR feels that better education of IMGs is potentially going to help with this problem.
4. After hours urgent or not
A popular 2015-16 category for review was the provision of urgent after-hours services. MBS urgent after-hours items pay a fair bit more than non-urgent, and doctors may be called for what may well be “urgent” to a mum or family in the middle of the night, but not urgent in the medical sense. The definition of urgent, some say, is that treatment cannot be delayed to the start of the next in-hours period in the opinion of the attending doctor. It can be a fine line. Or not. The PSR get a little shirty with doctors who bill urgent for things like uncomplicated rashes or reissuing prescriptions for a patient’s regular medication.
5. Put a giant tropical fish tank, a white grand piano or a red Lamborghini in your waiting room
OK, no one actually got pulled up for this, but we wouldn’t recommend it, based on the experience of a couple of past entrepreneurial doctors.
The PSR is an organisation looking for a reason not to exist, but in a largely fee-for-service system, probably always will. And in the near term, it’s highly likely the ratio and net number of doctors caught in the PSR net will continue to increase as the data the PSR gets becomes more sophisticated through computerisation, and they review and change their mode of operation, for instance, start to include the behaviour of entire practices and companies, in their assessments.
So for all you highly efficient and entrepreneurial doctors out there, make sure you cross the t’s and dot the lower case j’s.
