Review calls for MBS ‘speed limit’ on specialists

By Geir O'Rourke

21 Aug 2023

Specialists could be subject to a hard limit on the number of Medicare-subsidised consultations they provide per day under a proposal being considered by health officials.

The idea has been pitched in an independent report into the Professional Services Review (PSR) commissioned by the Federal Government, which argues that while restrictions are already in place via the 80/20 rule, these only impact GPs.

Set down in federal legislation, the 80/20 rule states a practitioner is automatically considered guilty of inappropriate practice if they render 80 or more services on 20 or more days in a 12 month period.

Exemptions exist for exceptional circumstances, although these are assessed at the discretion of the PSR and are rarely allowed.

Nevertheless, the Medicare watchdog revealed a decision in June to drop a case against a practitioner who had breached the rule due to exceptional circumstances relating to the COVID-19 pandemic.

No details were offered, but these would have “affected the rendering of the services [so] there were insufficient grounds on which a committee could reasonably find the practitioner engaged in inappropriate practice,” it said in an update last month (link here).

However, it appears there is an appetite in certain quarters for more targeted speed limits, with the independent review arguing additional criteria for ‘prescribed patterns of services’ are needed for specialists and allied health professionals.

Restrictions overdue

According to the report, published on the Department of Health website earlier this month (link here), these had already been recommended in a 2007 review and were now overdue.

The number of specialists coming before the watchdog had grown to comprise 25% of cases interviewed by the PSR director, it added.

“The existing definitions are long-standing and have been endorsed by the courts as appropriate,” wrote the review’s authors, legal expert Emeritus Professor Robin Creyke AO with GP and former AMA Queensland president Dr Dilip Dhupelia.

“There are, however, no legislative criteria for a ‘prescribed pattern of services’ for specialists and allied health professionals as was recommended in the 2007 review.”

The review focussed on negotiated agreements made under Section 92 of the Health Insurance Act between the PSR director and practitioners under investigation for alleged inappropriate use of Medicare and rejected claims the system was coercive.

It also dismissed an argument put forward by the AMA that the mental health toll of a PSR probe “contributed to practitioners accepting a section 92 agreement despite not believing that they had, in fact, acted inappropriately regarding their MBS billing practices”.

“People commonly face choices of that kind. Such choices often involve a degree of stress,” the report’s authors found.

Other recommendations included that the PSR improve transparency around its processes as well expand its guide to practitioners under review, actions which were already in train, according to the government.

In its official response, the Department of Health said the idea of a speed limit for specialists remained on the table.

“The recommendation, while not directly related to the scope of the review, is a matter that is being considered in ongoing policy development processes,” it said.

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