Practitioner Review Program - the 80 20 rule

Practitioner Review Programthe 80/20 rule

Under the Health Insurance Act 1973 practitioners are considered to have engaged in inappropriate practice if they have rendered or initiated services during a particular period which constitutes a prescribed pattern of services. The regulations associated with this Act define a prescribed pattern of services as rendering 80 or more professional attendances on 20 or more days in a 12 month period. This is known as the 80/20 rule.

The department has an obligation under the Act to review the practice profiles of all general practitioners and other medical practitioners on a regular basis. If practice profiles indicate the 80/20 rule has been exceeded, a request will be made to the Director of Professional Services Review to examine the services provided.

To assist practitioners, the department may make contact with a practitioner if they are approaching the 80/20 rule to alert the practitioner and discuss possible reasons for the pattern of services.

Please note, in addition to the compliance with the 80/20 rule, practitioners may also be included in the departments practitioner review program if there is concern:

that the item descriptor requirements have not been met, or

about the clinical relevance of the services provided.

To increase voluntary compliance among health professionals and ensure public monies are appropriately spent, the departments main approach is education. In addition to conducting reviews of claiming behaviour, the department aims to assist practitioners by providing information to support appropriate claiming.

For more information contact the Primary Care Support Team on 9477 8700 or email practice_support@nsml.com.au

Practitioner Review Programthe 80/20 rule