Medicare orders specialists to repay millions for inappropriate billing

Medical politics

By Tessa Hoffman

26 Nov 2018

The Medicare compliance watchdog is targeting specialists’ use of MBS items and has already clawed back millions for inappropriate claims.

In its latest annual report the Professional Services Review (PSR) says it has widened its enforcement actions beyond the traditional focus on GPs, to encompass specialists such as rheumatologists and haematologists.

In 2017/18 it recovered $20 million from specialists, GPs and other practitioners, with the amounts repaid ranging from $15,000 to $2 million and more than half involving amounts more than $200,000.

The PSR says its investigations into specialist billing focused on MBS consultation items 104 ($87) and 105 ($44).

“Findings of inappropriate practice have been made when consultation items have been billed in association with procedural items when there is no evidence of a separate consultation, there is a lack of a valid referral, and there is a concern about poor documentation of the patient history, examination, diagnosis and management plan by the specialist,” its report says.

“In some cases, consultations have been performed by assistants, with little evidence of clinical input from the specialist practitioner in the core elements of the medical consultation.

As a result, PSR Director Professor Julie Quinlivan has issued a warning to specialists in the PSR’s latest monthly update.

She notes that item 104 is for the first consultation in a single course of treatment, which means attendance on the patient until they are referred back to the referring practitioner, and any subsequent review of the patient’s condition whether initiated by the specialist or referring practitioner.

“I have concerns that on some occasions practitioners are billing MBS item 104 for multiple episodes in the same course of treatment, simply because they have received a new referral document,” she writes.

“In extreme cases, where specialists do not usually see patients more than once, I have been concerned that practitioners attempt to bill everything as MBS item 104 and only bill MBS item 105 if the initial claim is rejected by Medicare.”

Practitioners should consider whether an attendance is the first or subsequent and not “rely on Medicare rejecting a claim for MBS item 104 to submit a claim for MBS item 105”, says Professor Quinlivan.

To cope with the increase in referrals for specialist claims, the PSR has recruited specialists to join its panel, including Professor John Gibson, head of haematology at Royal Prince Alfred Hospital in Sydney, and Professor Mark Arnold, a rheumatologist and Head of Clinical School of Medicine at the University of Sydney’s School of Rural Health (Dubbo/Orange).

The PSR annual report also notes that the amount of money repaid by practitioners to Medicare has quadrupled from the $5 million in 2016-16 to $20 million in 2017-18.

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