Three stages of review
There are up to 3 stages in the review process, as detailed below.
Stage 1: PSR Director reviews the information
Stage 1 begins when a delegate of the Chief Executive Medicare asks the PSR Director to review the services provided by a practitioner or corporate entity during a specified period. Throughout the review process, this practitioner or corporate entity is called the 'person under review'.
If it appears to the Director that the person under review may have engaged in inappropriate practice, they will do a review of the data provided by the delegate. The Director may ask the person under review to provide patient records. They may also obtain assistance from a consultant or professional body.
After the data and records are examined, the Director may meet with the person under review.
The Director then provides a report to the person under review and considers any submission from them. The Director must then decide on one of the following options:
- to take no further action (dismiss the matter)
- to negotiate an agreement with the person under review if they are willing to acknowledge inappropriate practice, as set out in section 92 of the Act
- to refer the practitioner to a peer review Committee.
Stage 2: PSR Committee decides if inappropriate practice occurred
Stage 2 is a peer review process that occurs if any of the following occurs:
- the Director believes that the conduct of the person under review needs further investigation
- the person under review has chosen not to agree to a negotiated agreement
- the Determining Authority refuses to ratify an agreement.
The Director creates a Committee of peers by selecting practitioners from the PSR Panel. Practitioners on this panel are appointed by the Minister for Health, after consultation with the AMA and other professional bodies.
The Committee’s role is to decide whether the conduct of the person under review in providing or initiating services would be unacceptable to the general body of their peers. To do this, the Committee considers clinical records and any other material provided.
If the Committee forms the preliminary view that the person under review might have practised inappropriately, a hearing is held. At the hearing, the Committee will question the person under review about their practice and provision of services. The person under review can present oral and written evidence. After considering all the evidence, the Committee produces a draft report of its preliminary findings and provides a copy to the person under review.
If the Committee finds that no inappropriate practice has occurred, the matter is closed.
However, if the Committee finds that inappropriate practice has occurred, the person under review is given time to respond to the draft report. The Committee considers their response and decides whether to change its finding. The Committee then issues a final report to the person under review and the Determining Authority.
Stage 3: Determining Authority makes its decision
Stage 3 involves the Determining Authority, which has 2 main duties:
- deciding if it should ratify negotiated agreements between the Director and person under review who has agreed to acknowledge inappropriate practice (see Stage 1).
- deciding what sanctions to impose when a PSR Committee finds inappropriate practice (see Stage 2).
When a Committee finds that the conduct of a person under review has been inappropriate, the Determining Authority invites them to make a submission about the sanctions it should impose. The Authority will consider the submission and prepare a draft determination that includes at least one of the following sanctions:
- a reprimand
- an order to repay any benefits for services that were provided inappropriately
- partial disqualification from claiming a Medicare or CDBS benefit for up to 3 years
- full disqualification from claiming a Medicare or CDBS benefit for up to 3 years
- full disqualification from the PBS for up to 3 years.
If there has been a previous occasion when the practitioner under review has either acknowledged inappropriate practice or been found to have practised inappropriately, the maximum period of disqualification is 5 years, rather than 3.
A person under review is also given an opportunity to make a written submission on the draft determination. The Determining Authority will consider this submission before making a final determination.
This is the end of the PSR process, unless the person under review appeals for judicial review to the Federal Court.
All of PSR’s key decision-makers are statutory appointments:
- The PSR Director is an independent statutory officer appointed by the Minister for Health. The Director must be a medical practitioner, and the Australian Medical Association (AMA) must agree to the appointment.
- A PSR Committee is set up by the Director as needed to consider specific cases. It has at least 3 members and typically includes one PSR Deputy Director as chair and 2 other members of the PSR Panel.
- The Determining Authority is an independent body within the PSR Scheme. It has 2 permanent members: a Chair, who must be a medical practitioner, and a lay person. For each case that it considers, it also includes a third member, a person who practises the same profession as the person under review. The Minister for Health appoints all members after consulting with the AMA and relevant professional bodies.