Agency overview
Operation of the PSR Scheme
Fundamental elements of the PSR Scheme are requests to review from Medicare Australia, PSR’s processes, activities of the Determining Authority, the Medicare Participation Review Committee and the judicial review process through the Federal Court.
Medicare Australia requests to review
Medicare Australia asks the Director of PSR to review a practitioner’s provision of services if it considers he or she may have provided those services inappropriately based on statistical data and other information.
Medicare Australia only has access to claims data and any information elicited by a medical adviser during a visit to a practitioner or from a practitioner’s written submissions. As a result, the reasons Medicare Australia seeks review of the provision of services generally fall within one or more select and distinct categories, namely:
- Prescribed pattern of services
- High volume of services
- High number of services per patient
- High prescribing of PBS drugs
- Inadequate clinical input
- MBS item not satisfied
- Services not medically necessary.
Professional Services Review’s process
The Director undertakes a review of the data received from Medicare Australia and may also direct the practitioner to produce a sample of medical records. Following examination of the medical records, a report to the practitioner and consideration of any submission received from the practitioner, the Director must:
- decide to take no further action
- enter into an agreement, or
- establish and make a referral to a peer review Committee.
No further action
Where the Director decides to take no further action, the Director writes to the person under review and Medicare Australia informing them of the outcome of the review.
Agreement
The Director may enter into a negotiated agreement with a practitioner. Both parties sign a document containing an acknowledgement by the practitioner that he or she has engaged in inappropriate practice. It may also contain an agreement for repayment of Medicare benefits and partial or full disqualification from Medicare. The Determining Authority must ratify this agreement. While the name of the practitioner remains confidential, the details of the inappropriate practice are published.
Committee
Where the Director considers the conduct of the person under review needs further investigation, a Committee is established. The Committee comprises members drawn from the panel appointed by the Minister for Health and Ageing. The Committee may conduct a hearing where the person under review can provide both oral and written evidence in support of their case.
After considering all the evidence and taking into account any submissions received, the Committee produces a draft report containing findings on the conduct of the person under review. Where the findings are that the person under review has not practiced inappropriately, the matter concludes. Where the findings are of inappropriate practice, the person under review is given time to make submissions on the draft report. After considering those further submissions a final report of any inappropriate practice is then forwarded to the Determining Authority.
Determining Authority
The Determining Authority is a separate body whose role is to determine the sanctions to be applied in cases of inappropriate practice.
On receipt of a Committee’s final report containing findings that the person under review has engaged in inappropriate practice the Determining Authority must invite written submissions on any sanctions that may be applied, issue a draft determination, seek comments from the person under review on the draft determination and issue a final determination containing sanctions.
The sanctions may include reprimand and counselling by the Director, repayment of Medicare benefits and partial or full disqualification from Medicare for a maximum of three years. When a final determination comes into effect the Director can publish certain details, including the practitioner’s name and address, profession or speciality, nature of the inappropriate practice and sanctions imposed.
Medicare Participation Review Committee
When a practitioner has had two effective final determinations the Director must provide a written notice to the Medicare Participation Review Committee. This Committee has a discretionary range of options available from taking no further action against the practitioner to counselling and reprimand and full or partial disqualification from participation in the Medicare benefits arrangements for up to five years.
Federal Court
At any stage in the process the person under review may seek judicial review in the Federal Court.