Key Takeaways
- The 80/20 rule triggers an automatic, mandatory referral to the Professional Services Review if a practitioner bills 80 or more services on 20 or more days in a rolling 12-month period - there is no discretion once the threshold is breached.
- Telehealth counts: phone and video consultations are included in the daily service total, and a separate 30/20 rule applies specifically to telephone services.
- PSR sanctions range from repayment of Medicare benefits to disqualification from billing for up to five years, and PSR material can now be shared with AHPRA under 2025 legislation.
- Track daily service counts per practitioner on a rolling basis and flag any day approaching 80 total services or 30 telephone services - proactive monitoring is the single most effective prevention.
- Ensure clinical records substantiate every Medicare claim against the MBS item descriptor, especially for complex items like consultant physician items 132 and 133.
If you are a GP or practice manager in Australia, Medicare compliance has probably never felt more front-of-mind. The Department of Health and Aged Care (DoHAC) has ramped up enforcement significantly, sending targeted awareness letters to GPs in March 2025 warning them about the 80/20 rule and publishing a Health Provider Compliance Strategy covering 2025 through 2030 with eight priority areas. The Philip Review estimated that Medicare loses between $1.5 and $3 billion each year to non-compliance, and Parliament responded with the Medicare Integrity Act in 2025 to tighten the screws. For most practices the issue is not fraud but inadvertent over-servicing, and the consequences of tripping a threshold can be severe. Here is what you need to know to stay on the right side of the rules.
What Is the 80/20 Rule and How Does It Work?
The 80/20 rule is a "prescribed pattern of services" under the Health Insurance Act 1973. Put simply, if a GP or other medical practitioner bills 80 or more professional attendance services on each of 20 or more days in any rolling 12-month period, they are automatically referred to the Professional Services Review (PSR). There is no discretion here. Once the threshold is breached, referral is mandatory.
It is important to understand that the count is 80 services per day, not 80 patients. A single patient visit can generate multiple service claims, so the number can add up faster than you might expect. Since July 2022, the count includes telehealth consultations alongside face-to-face services. Video calls and phone calls all count toward the daily total.
The 30/20 Rule for Telephone Services
On top of the 80/20 rule, a separate 30/20 threshold applies specifically to telephone consultations. If a practitioner provides 30 or more telephone attendance services on each of 20 or more days in a 12-month period, that also triggers an automatic PSR referral. This rule extends beyond GPs to cover consultant physicians and specialists, making it particularly relevant for practices with visiting specialists who do phone follow-ups. Phone services count toward both rules simultaneously, so a GP doing 30 phone consults in a day has those 30 also counted toward the 80 service daily threshold.
What Happens When You Get Referred to the PSR
The Professional Services Review is a three-stage process, and understanding it takes some of the fear out of it.
Stage 1: Director's Review
A Delegate of the Chief Executive Medicare sends your claiming data to the PSR Director, who reviews your billing patterns over a specified period. The Director may request your patient records and can consult with professional bodies. At this point, three things can happen: the matter is dropped for insufficient evidence, you negotiate an agreement acknowledging inappropriate practice and accept terms, or the case escalates to Stage 2.
Stage 2: Peer Committee Review
An independent committee of your professional peers is established, with at least three members drawn from a panel appointed by the Minister for Health. The Chair must be a member of your profession, and at least two committee members will share your specialty. The committee's test is straightforward: would your conduct be considered unacceptable by the general body of your peers? You will have the opportunity to respond before any final report is issued.
Stage 3: The Determining Authority
If the committee finds inappropriate practice occurred, the Determining Authority decides on sanctions. These range from a formal reprimand or counselling through to repayment of Medicare benefits and partial or full disqualification from billing MBS, PBS, or CDBS for up to three years. If you have a prior finding of inappropriate practice, the maximum disqualification period extends to five years. Under new legislation passed in 2025, PSR material can now be shared with AHPRA, meaning your professional registration could also come under scrutiny.
DoHAC's Eight Compliance Priority Areas
The Health Provider Compliance Strategy sets out eight areas that DoHAC is actively monitoring. Knowing these helps you understand where enforcement attention is focused.
The first priority is bulk billing practices, specifically around membership fees and co-payments. Charging any additional fee for a bulk-billed service breaches the Health Insurance Act, and DoHAC has reported multiple open cases involving practices charging administrative fees while bulk billing. The second area is opportunistic billing and emerging business models, particularly those that prioritise revenue over clinically relevant patient care or remove provider control over claiming decisions.
Duplicate payments are the third focus area, targeting redundant or repeated claims. Fourth is claiming MBS services while overseas, since telehealth services billed while the practitioner is physically outside Australia are prohibited. Suspected fraud sits as the fifth priority, covering outright fraudulent claims.
The sixth area covers specialist and consultant physician claiming, with particular attention to attendance items and management plan claims like items 132 and 133, which require documented complex treatment plans. The seventh and eighth areas relate to the Pharmaceutical Benefits Scheme: high-cost PBS medicines and open or uncertified PBS claims.
Practical Steps to Keep Your Practice Compliant
The good news is that staying compliant is largely about building good monitoring habits into your practice operations.
Start by generating regular billing pattern reports for each practitioner. Track daily service counts against the 80/20 and 30/20 thresholds on a rolling 12-month basis. Flag any day where a practitioner approaches 80 total services or 30 telephone services. This kind of proactive monitoring is the single most effective way to avoid an accidental threshold breach.
Reconcile your practice bank accounts with your accounting software on weekly, monthly, and quarterly cycles. Discrepancies between financial records and bank statements can signal billing issues before they escalate to DoHAC's attention.
Make sure your clinical records can substantiate every Medicare claim. If your records cannot demonstrate that the service billed was actually provided as described in the MBS item descriptor, you are exposed. This is especially important for complex items like consultant physician items 132 and 133, which have specific time, morbidity, and documentation requirements.
Regularly brief your practitioners on MBS item descriptor requirements. Many compliance issues stem from genuine misunderstanding of what an item covers, not from any intent to over-claim. DoHAC's AskMBS email advisory service is a useful resource for clarifying item descriptors and associated legislation.
If your practice bulk bills, audit your fee processes to ensure zero additional charges are being levied. This includes administrative fees, membership fees, and any other charges associated with a bulk-billed consultation.
Finally, investigate anomalies early. A sudden spike in a practitioner's daily service count or an unusual pattern in telehealth billing is much easier to address internally than after DoHAC sends a letter.
How ClinicComply Helps You Stay on Top of Medicare Compliance
Keeping track of compliance obligations across Medicare, accreditation, privacy, and workplace safety is a lot for any practice manager to juggle. ClinicComply gives you a centralised compliance dashboard where you can track regulatory requirements, manage documentation, and maintain audit-ready records, all in one place. Instead of spreadsheets and filing cabinets, you get a clear view of where your practice stands and what needs attention. Start your free trial at cliniccomply.com.au.