What you need to knowA GP or OMP engages in inappropriate practice if they have rendered or initiated 80 or more professional attendance services on each of 20 or more days in a 12 month period (known as a 'prescribed pattern of services'). This is commonly referred to as the "80/20 rule".
The 80/20 rule is based on the number of professional attendance services per day, which may not be the same as the number of patients seen in a day. GP and OMP professional attendance services include the following groups as listed in the Health Insurance (Professional Services Review Scheme) Regulations 2019:
- A1 General practitioner attendances to which no other items applies
- A2 Other non-referred attendances to which no other item applies
- A5 Prolonged attendances to which no other item applies
- A6 Group therapy
- A7 Acupuncture
- A9 Contact lenses - attendances
- A11 Urgent attendances after hours
- A13 Public health physician attendances to which no other item applies
- A14 Health assessments
- A15 GP management plans, team care arrangements and multidisciplinary care plans and case conferences
- A16 No professional attendance items are currently listed in this Group
- A17 Domiciliary and residential medication management reviews
- A18 General practitioner attendances associated with Practice Incentive Program (PIP) payments
- A19 Other non-referral attendances associated with PIP payments to which no other items applies
- A20 Mental health care
- A21 Medical practitioner (emergency physician) attendances to which no other item applies
- A22 General practitioner after-hours attendances to which no other item applies
- A23 Other non-referred after-hours attendances to which no other item applies.
If you exceed the 80/20 level of servicing, you will be reviewed under the Practitioner Review Program (PRP).
The Health Insurance Act 1973 requires a request to be made to the Director of Professional Services Review (the Director) if the delegate of the Chief Executive Medicare (delegate) becomes aware of a breach of the 80/20 rule. Once the PRP has verified that the medical servicing data indicates that a breach of the 80/20 rule has occurred, and you have been contacted and the matter has been assessed by a delegate, a request will be made to the Director to review your provision of services.