1999 Amendments - Review of the PSR Scheme

A comprehensive review of the PSR Scheme was undertaken in 1999 in response to Federal Court and Full Federal Court decisions (1997 and 1998, respectively) in the Yung case which had significant impact on the Scheme’s administration.

The PSR Scheme was substantially amended following the 1999 Review and the legislative changes to the Scheme were authorised by amendments to the Act contained in the Health Insurance Amendment (Professional Services Review) Act 1999.

The Act provided for improvements to the administration of the Scheme including:

  • increasing the investigation, case preparation and negotiation powers of the Director
  • providing for legal support to the peer review Committees
  • allowing greater legal support to the practitioner under review
  • replacing the Determining Officer with a Determining Authority comprising a permanent chair (medical practitioner), a permanent lay person and a third member who is a representative of the profession of the person under review and
  • removing the PSR Tribunals from the process whilst retaining the right of review on points of law.

The Act also provided for a range of different methods for investigating inappropriate practice including the introduction of:

  • 'deeming provisions' in respect of high volume servicing per day. Once a practitioner reaches or exceeds the specified volume of services,  he or she will be deemed to have been practising inappropriately unless exceptional circumstances can be demonstrated to the satisfaction of the Committee of peers
  • sampling methodologies to be used by Committees to make findings in relation to the provision of particular identifiable services and to be able to extrapolate the results to a larger number of similar services within the referral and
  • generic findings to allow Committees to make a finding of inappropriate practice where, on the evidence available, it is not possible to identify or quantify specific services. This would apply where there is an absence, deficiency or illegibility of clinical or practice records and a Committee cannot base its inquiry on the deeming provisions or sampling.

 Other related matters contained in the Act included:

  • provision to allow for the publication of details, including the name of the practitioner once a final determination of inappropriate practice is made
  • the introduction of a requirement that a Committee must, in determining whether a practitioner has engaged in inappropriate practice, have regard to whether or not the practitioner kept adequate and contemporaneous medical records
  • the ability to continue a consideration of inappropriate practice where fraud is suspected and these concerns have been referred back to the Heath Insurance Commission and
  • administrative penalties to apply for the person under review or other persons for failing to produce documents.

Related Legislation