1. Agency overview
The PSR Scheme
The object of the PSR Scheme is to protect the integrity of the Medicare and pharmaceutical benefits programs by:
- protecting patients and the community in general from the risks associated with inappropriate practice
- protecting the Commonwealth from having to meet the cost of services provided as a result of inappropriate practice.
The PSR Scheme was developed to provide an effective peer review mechanism to deal quickly and fairly with concerns about possible inappropriate practice.
A practitioner engages in inappropriate practice if his or her conduct, in connection with rendering or initiating services, is such that the conduct would be unacceptable to the general body of the group (that is, medical practitioner, dentist, optometrist, chiropractor, physiotherapist, osteopath or podiatrist) in which the practitioner was practising.
A person who is an officer of a body corporate engages in inappropriate practice if the person causes or permits an employee to engage in inappropriate practice.
Key players in the PSR Scheme are:
- The Director of PSR, who is a medical practitioner appointed by the Minister for Health and Ageing with the agreement of the Australian Medical Association. Dr Anthony Webber was appointed Director of PSR on 14 February 2005 for a three-year period. Dr Webber’s appointment was extended for a further three-year term from 14 May 2008.
- The PSR Panel, comprising medical and other health care practitioners, who are appointed by the minister. At 30 June 2009, 158 members of the panel were available to serve on Committees. Of these, 19 were also appointed as Deputy Directors of PSR to serve as chairpersons of Committees.
- PSR Committees, comprising members of the PSR Panel, established by the Director on a case-by-case basis to consider the conduct of practitioners.
- The Determining Authority, comprising a medical practitioner as Chair, a layperson and a member of the relevant profession. The minister appoints members of the Determining Authority. The Determining Authority’s role is to decide on sanctions for practitioners found by Committees to have engaged in inappropriate practice and to consider whether to ratify agreements entered into by the Director and practitioners under review.
- Medicare Australia that makes requests to the Director of PSR to review provision of services by practitioners.
- The Australian Government Department of Health and Ageing that has responsibility for legislation and policy relating to the PSR Scheme.
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 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. The reasons Medicare Australia seeks review of provision of services generally fall within distinct categories, including:
- prescribed pattern of services
- high volume of services
- high number of services per patient
- high prescribing of Pharmaceutical Benefits Scheme (PBS) drugs
- inadequate clinical input
- Medicare Benefits Schedule (MBS) item not satisfied
- services not clinically necessary.
Cases of possible fraud PSR identifies in the course of its investigations are referred back to Medicare Australia for action.
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 patient records. Following examination of the 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, he 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 the person under review. 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 the agreement for it to have effect. While the name of the practitioner remains confidential, the details of the inappropriate practice may be 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 practitioner can provide both oral and written evidence in support of their case.
After considering all the evidence, the Committee produces a draft report containing findings on the practitioner’s conduct. Where the Committee finds that the person under review has not practised 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 person under review and the Determining Authority.
Determining Authority
The Determining Authority’s role is to determine the sanctions to be applied in cases where Committees have found inappropriate practice, and to decide whether to ratify negotiated agreements.
On receipt of a Committee’s final report containing findings of 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 may publish certain details, including the practitioner’s name and address, profession or specialty, nature of the inappropriate practice and sanctions imposed.
Medicare Participation Review Committees
When a practitioner has attracted two effective final determinations the Director must provide a written notice to the Chairperson of the Medicare Participation Review Committees. Such committees have a discretionary range of options available, from taking no further action 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.