Key Takeaways
- In the Professional Services Review Director's updates through 2025 and into 2026, the dominant triggers were non-individualised chronic disease management plans and breaches of the 80/20 and 30/20 rules, not exotic billing schemes.
- September 2026 brought 18 section 92 agreements with repayments totalling $4,519,218, from $22,000 to $750,000. Eight of them disqualify the practitioner from GP chronic condition management plan items (965, 967 or their video equivalents 92029 and 92030) for 3 to 12 months.
- A PSR Committee final determination effective 18 September 2026 ordered a GP to repay $300,000, approximately 90% of the Medicare benefits paid for the services found to be inappropriate practice, after finding the GPMPs and TCAs were "generic templates not adequately individualised for the patient".
- In September 2025, one GP agreed to repay $290,000 over a breach of the 80/20 rule, and another agreed to repay $595,000, accept a 12-month disqualification from chronic disease management items and be reprimanded by the Director.
- In one July 2025 reporting period, 10 GPs entered Section 92 agreements with repayments ranging from $106,000 to $700,000.
- The 80/20 rule (80+ relevant attendances, face to face, video or phone, on each of 20+ days) and the 30/20 rule (30+ phone attendances) both trigger a mandatory referral to the PSR under the Health Insurance Act 1973.
- Since 1 July 2025 the GP Chronic Condition Management Plan replaced the GPMP and Team Care Arrangement, so legacy care plan templates carried into the new item numbers now compound PSR documentation risk during the transition period to 30 June 2027.
The Professional Services Review (PSR) is targeting non-individualised care plan templates and high-volume billing in 2026. The clearest pattern across recent Director's updates is repayment orders, often well into six figures, where GP management plans, team care arrangements and chronic disease management services were billed against documentation that auditors judged generic, clinically thin or non-compliant with the MBS item requirements.
Status check, 20 October 2026: updated with the PSR Director's update for August 2026 (published 17 September 2026) and the update for September 2026 (published 15 October 2026), which carries a PSR Committee final determination that turned on care plan templates. The 2025 cases below are unchanged.
What is the PSR and why does it matter in 2026?
The Professional Services Review is an independent statutory scheme that reviews whether a practitioner has engaged in "inappropriate practice" when rendering or initiating Medicare and PBS services. It sits separate from Services Australia compliance audits and from AHPRA. Where the Department of Health, Disability and Ageing identifies a concern, it can request the PSR Director to review the practitioner's provision of services. Most matters resolve through a negotiated Section 92 agreement rather than a full Committee hearing, and those agreements routinely include repayment of benefits, disqualification from billing specific items, counselling or a reprimand.
What makes 2026 different is not a new rule. It is the consistency of the pattern in the PSR Director's updates, where chronic disease management documentation and prescribed-pattern billing keep producing the largest repayment orders. For any practice running care plans at volume, that pattern is the risk signal worth acting on.
What is the PSR targeting most in 2026?
The recurring theme is documentation that does not support the service billed, especially for chronic disease management. In its November 2025 update, the PSR described concerns that a practitioner's records did not always reflect that the patient had a chronic disease or mental health condition, and that chronic disease management items were billed on days proximate to standard professional attendances. The September 2025 update recorded persisting concerns that clinical input was not adequate for chronic disease management services, that associated documents were poor quality, that plans were not comprehensive, that they did not demonstrate active collaboration with other providers when required, and that reviews did not provide adequate progress updates.
The Department of Health groups the common findings into six issues that put practitioners in the PSR's sights. They are summarised below, because each one maps directly to something a practice can check in its own records.
| Common PSR finding | What it means in a care plan context |
|---|---|
| MBS requirements not met | The item's mandatory steps (for example, collaboration or review components) are absent from the record |
| Inadequate records | The note does not justify the service or assist another practitioner to manage the patient |
| Insufficient clinical input | The practitioner's own contribution is minimal; the plan reads as administratively generated |
| Not all services clinically indicated | Plans or reviews billed without a clear clinical need at that point in time |
| Patient consent not adequately recorded | Consent to the service is not documented where required |
| Prescribing without appropriate clinical indication | PBS prescribing not supported by the clinical record |
Source: Department of Health, Disability and Ageing, reported via The Medical Republic.
Can a care plan template trigger a PSR review?
A template does not trigger a review by itself, but the way a template is used is repeatedly at the centre of inappropriate practice findings. The problem the PSR describes is sameness: plans that read identically across patients, goals that are not specific to the person, review entries that do not record actual progress, and an absence of evidence that other providers were genuinely involved. When a reviewer compares a sample of plans and finds the clinical content interchangeable, the conclusion is that the practitioner's clinical input was insufficient and the documentation does not meet the item requirements.
This matters more in 2026 because of a structural change. From 1 July 2025 the GP Chronic Condition Management Plan (GPCCMP) replaced the older GP Management Plan and Team Care Arrangement, with a transition period running to 30 June 2027. Practices that simply pasted their old GPMP and TCA wording into the new GPCCMP item numbers carried any pre-existing template weakness straight into the new framework. For the full detail of the new item structure and transition dates, see our telehealth and chronic condition Medicare billing guide. The compliance point here is narrower: a generic plan was a risk before the change, and it is a compounding risk now that the same content sits under new items with their own requirements.
How large are recent PSR repayment orders?
Recent agreements show the financial scale. The figures below are drawn directly from PSR Director's updates and reported reporting-period summaries.
| Case (period) | Issue | Outcome |
|---|---|---|
| GP, September 2025 | Standard professional attendances; 80 or more attendances on 20 or more days | Repay $290,000; counselling |
| GP, September 2025 | Attendance and chronic disease management items; PBS prescribing; prescribed pattern of services | Repay $595,000; 12-month disqualification from chronic disease management items; reprimand |
| 10 GPs, July 2025 period | Section 92 agreements across the period | Repayments from $106,000 to $700,000 |
| Practitioners, November 2025 | Documentation and chronic disease management billing concerns | Repay $59,000 each; counselling |
| 12 practitioners, August 2026 | Section 92 agreements, including one 80/20 finding (80 or more relevant services on each of 27 days) | $2,768,251.85 in total; the 80/20 case repaid $450,000 with a 12-month disqualification from item 91801 |
| 18 practitioners, September 2026 | Section 92 agreements: 14 GPs, 2 medical practitioners, an obstetrician and gynaecologist, an ENT surgeon | $4,519,218 in total, from $22,000 to $750,000; eight disqualifications from GPCCMP items of 3 to 12 months |
| GP, PSR Committee final determination effective 18 September 2026 | Items 36, 44, 703, 721, 723, 2715 and 10660, and PBS item 1916W; GPMPs and TCAs that were generic templates | Repay $300,000, about 90% of the benefits paid for those services; 18-month disqualification from items 703, 965, 967, 92029, 92030, 2715 and 92116; reprimand |
The $595,000 case from September 2025 is the one to study among the older matters. The 12-month disqualification covered the chronic disease management items the practitioner had been billing, alongside the repayment and reprimand, which shows the PSR is willing to remove access to care planning item numbers entirely, not just claw back benefits. The September 2026 update shows the same approach applied at scale. The full item-level detail for each case is set out in the relevant PSR Director's update linked above.
What did the PSR's September 2026 update show?
The September 2026 update, published 15 October 2026, records 18 section 92 agreements that came into effect in the month, with repayments from $22,000 to $750,000 and $4,519,218 in total. The practitioners were 14 GPs, 2 medical practitioners, an obstetrician and gynaecologist and an ENT surgeon. Care plan documentation runs through most of the GP matters. The persisting concerns include plans that were "not personalised to the particular patient", documentation that "often lacked personalised and measurable goals", plans "closely resembling previous assessments and plans", and records "based on generic templates insufficiently individualised to the patient".
Eight of the 18 agreements disqualify the practitioner from the GP chronic condition management plan items (965 and 967, or their video equivalents 92029 and 92030) for between 3 and 12 months. In all eight, the services reviewed included the old GPMP and TCA items 721 and 723. The PSR is attaching the consequence to the GPCCMP items that replaced them on 1 July 2025, so a practitioner with a template problem under the old items loses access to the new ones.
The same month carried a PSR Committee final determination, effective 18 September 2026. The Committee found a GP had engaged in inappropriate practice across items 36, 44, 703, 721, 723, 2715 and 10660 and in prescribing PBS item 1916W. The Determining Authority directed the GP to repay $300,000, "which reflects approximately 90% of the Medicare benefits paid for the services in connection with which the practitioner was found to have engaged in inappropriate practice", and disqualified the GP from items 703, 965, 967, 92029, 92030, 2715 and 92116 for 18 months and from items 36 and 44 for 6 months. For items 721 and 723 the Committee found the MBS requirements were not met "because the general practitioner management plans (GPMPs) and team care arrangements (TCAs) were generic templates not adequately individualised for the patient". It also found the GP "relied heavily on templates and failed to adequately personalise each entry for the specific patient and service".
Other patterns in the September 2026 agreements:
- Seven 30/20 findings. Seven practitioners rendered 30 or more relevant phone services on each of 23, 24, 25, 25, 30, 33 and 56 days. There was no 80/20 finding that month. In one further case, which repaid $750,000, the Associate Director was satisfied that exceptional circumstances existed for the prescribed pattern.
- Practice nurse work. Four agreements raised services involving a practice nurse: item 10997 or other co-billed nurse services where no separate nurse service was provided, item 10997 billed with health assessments and chronic disease management services where the nurse performed the related tasks, and GP items where the service may have been provided by the nurse.
- Telehealth eligibility. One practitioner claimed services, including some in-person services, while not in Australia, and agreed to repay $183,718 with a 36-month disqualification from items 36, 5040, 91801, 91802 and 91891. Another rendered telehealth services where they were not the patient's usual medical practitioner ($40,000). The unsociable hours video items 92210 and 92211 appear in three agreements.
The August 2026 update, published 17 September 2026, recorded twelve section 92 agreements totalling $2,768,251.85. Its one 80/20 finding, 80 or more relevant services on each of 27 days, ended in a $450,000 repayment and a 12-month disqualification from item 91801. Our Medicare 80/20 rule guide covers what now counts toward that threshold.
What is the difference between the 80/20 and 30/20 rules?
Both are "prescribed pattern of services" rules under the Health Insurance Act 1973, and both produce a mandatory referral to the PSR. The difference is the type of service counted.
| Rule | What is counted | Threshold | Who it applies to |
|---|---|---|---|
| 80/20 rule | Relevant professional attendance services, face to face, video and phone | 80 or more on each of 20 or more days in any 12-month period | Medical practitioners rendering relevant attendance items |
| 30/20 rule | Phone (telephone) attendance services | 30 or more on each of 20 or more days in any 12-month period | GPs, other medical practitioners in general practice, and consultant physicians |
When either threshold is met, the practitioner is taken to have engaged in inappropriate practice, and the delegate is required to request a PSR review. There is no discretion at the referral stage. The official explanation of how these breaches are detected is published by the Department of Health.
What counts changed on 13 August 2026. The Health Insurance (Professional Services Review Scheme) Amendment (Prescribed Pattern of Services) Regulations 2026 (F2026L01049) rewrote the definitions of relevant service and relevant phone service, so DVA-funded attendances that would otherwise have attracted a Medicare benefit now count toward both rules alongside Medicare services. The item lists were also refreshed: all items in Group A48 were added to the 80/20 list, and groups and subgroups no longer in the general medical services table were removed. The thresholds themselves did not move. For the full detail, and what practices need to change in their daily servicing reports, see our Medicare 80/20 rule guide.
How can a practice reduce PSR risk on chronic disease items?
The defensible position is a care plan that a reviewer could read in isolation and accept as individualised. The practical checks that follow from the recent findings are:
- Make each plan patient-specific in its problems, goals and actions, not just in the demographic fields. Goals copied verbatim across patients are the clearest red flag.
- Record genuine collaboration where the item requires it. For team-based items, the record should show that other providers contributed, not just that their names were listed.
- Document reviews as actual progress against the plan, including what changed, rather than a date stamp with boilerplate text.
- Confirm the clinical indication exists at the time of billing, and that the patient meets the chronic disease criteria the record relies on.
- Check item timing. Billing a chronic disease management item on a day proximate to a standard attendance was specifically flagged in the November 2025 update.
- Audit a random sample of your own plans the way a reviewer would: pull ten at random and ask whether they read as ten different patients.
These are also the documentation standards that protect mental health treatment plans and other team-based items, which the PSR reviews on the same principles. If your practice runs Better Access alongside chronic disease care, our Better Access mental health billing compliance guide covers the parallel documentation requirements.
Frequently Asked Questions
What are the most common reasons the PSR reviews GPs in 2026?
The most common reasons are documentation that does not support the service billed and breaches of the prescribed-pattern rules. Through 2025 the PSR repeatedly cited non-individualised chronic disease management plans, inadequate clinical input, missing collaboration and progress reviews, and rendering 80 or more attendances on 20 or more days. The Department of Health groups these into six recurring findings.
Can a care plan template trigger a review?
Not on its own, but template misuse is central to many findings. When plans read identically across patients, when goals are generic, and when review entries record no real progress, the PSR concludes the practitioner's clinical input was insufficient and the MBS item requirements were not met. Templates are acceptable; non-individualised content billed at volume is the risk.
How large are recent repayment orders?
The September 2026 update recorded 18 section 92 agreements totalling $4,519,218, from $22,000 to $750,000, and a PSR Committee determination ordering a GP to repay $300,000 for template-based care plans. August 2026 recorded twelve agreements totalling $2,768,251.85. Earlier cases include $290,000 and $595,000 in September 2025. Most matters resolve by negotiated agreement rather than a full hearing.
What is the difference between the 80/20 and 30/20 rules?
Both are prescribed-pattern-of-services rules under the Health Insurance Act 1973. The 80/20 rule counts relevant attendances, face to face, video and phone: 80 or more on each of 20 or more days in a 12-month period. The 30/20 rule counts phone attendances only: 30 or more on each of 20 or more days. Meeting either threshold means the practitioner is taken to have engaged in inappropriate practice and is referred to the PSR.
How can a practice reduce PSR risk on chronic disease items?
Make every plan genuinely patient-specific, document real collaboration where the item requires it, record reviews as actual progress, and confirm the clinical indication and chronic disease criteria are met before billing. Watch item timing, particularly chronic disease items billed close to standard attendances. Audit a random sample of your own plans periodically to test whether they read as distinct patients.