The three stages of review

The PSR Scheme provides for the separation of the decision-making process and has three main stages.

Stage 1: Consideration by the Director of whether there is sufficient evidence that would enable a Committee of peers to determine if inappropriate practice may have occurred. Alternatively, if the practitioner is willing to acknowledge inappropriate practice, the practitioner and the Director may seek to negotiate an agreement.

Stage 2: A peer review process by a PSR Committee to determine if inappropriate practice has occurred.

Stage 3: Consideration and setting of an appropriate outcome by the Determining Authority.

SUMMARY OF STAGE 1 – Review by the Director

Decision on whether the matter should be reviewed

The PSR process begins when a Delegate of the Chief Executive Medicare requests the Director to undertake a review of the provision of services by a practitioner over a specified period.

A review must be undertaken if, after considering the request, the Director forms the opinion that the practitioner may have engaged in inappropriate practice.

The Director undertakes a review of the data received from the delegate, and may also direct the practitioner to produce complete and original patient records. After the records are examined, the Director may meet with the practitioner. A report on the findings is made and any submission received from the practitioner is considered. The Director must then decide to:

  1. take no further action
  2. negotiate an Agreement under Section 92 of the Act, or
  3. refer the practitioner to a peer review Committee.

SUMMARY OF STAGE 2 – Review by a Committee

Decision on whether inappropriate practice occurred

If the Director considers that the conduct of the practitioner needs further investigation, or the practitioner chooses not to enter a Negotiated Agreement, a Committee of the practitioner’s peers is established. Members are drawn from the Panel appointed by the Minister.

The Committee determines whether the practitioner’s conduct in connection with the rendering or initiation of services would be acceptable to the general body of their peers. The Committee uses clinical records and any other material provided by the practitioner to make this decision.

If, after considering the information provided, the Committee forms a preliminary view that the practitioner may have engaged in inappropriate practice, a hearing is held. The hearing provides the practitioner with the opportunity to present both oral and written evidence to support their case. After considering all the evidence, the Committee produces a Draft Report containing its findings and provides a copy to the practitioner.

If the Committee finds that no inappropriate practice has occurred, the matter is closed. If the Committee finds that inappropriate practice has occurred, the practitioner is given time to make submissions on the Draft Report. The Committee then considers the practitioner’s submissions and may or may not change their findings. The Committee then issues a Final Report to the practitioner and the Determining Authority.

SUMMARY OF STAGE 3 – Determining Authority

Decision on a suitable sanction

The Determining Authority is an independent body within the PSR Scheme. The Determining Authority has two main functions, which are to:

  • decide whether to ratify Negotiated Agreements reached between the Director and a practitioner
  • determine what sanctions to apply when a Committee finds that a practitioner has engaged in inappropriate practice.

When a Committee makes a finding of inappropriate practice against a practitioner, the Determining Authority will invite submissions from the practitioner on the sanctions it should impose. The Determining Authority will prepare a Draft Determination, including the sanctions it intends to impose.

The Determining Authority must impose one or more of the following sanctions:

  • a reprimand
  • counselling
  • partial disqualification from claiming a Medicare benefit for no more than three years
  • full disqualification from claiming a Medicare benefit for no more than three years
  • an order for repayment of any Medicare benefits for services provided in the review period that have been found as being provided inappropriately
  • a full disqualification from the PBS for no more than three years.

Practitioners are given an opportunity to make written submissions on the Draft Determination. The Determining Authority will consider this submission and then make a Final Determination. The Final Determination contains the final decision of PSR and is the end of the PSR process, unless the practitioner appeals to the Federal Court or Federal Magistrates Court.