Review by the Director

This content is prepared for employers, including corporate entities &/or their related officers, subject to a review under Part VAA of the Health Insurance Act 1973.

Overview of the Director’s review

The following section has been prepared to explain the Director’s review. The Director has decided to undertake a review because, after considering a request from a delegate of the Chief Executive Medicare, it appears to the Director that there is a possibility that you engaged in inappropriate practice during the review period.

The Director has notified you and the Chief Executive Medicare of the decision to undertake a review.

The Director’s review will focus on the rendering or initiation of MBS services and/or prescribing of PBS listed medications by practitioners employed or otherwise engaged by you and your role in causing or permitting those practitioners’ conduct .

Soon after deciding to undertake a review, the Director will send you and/or a third party (or parties) a notice to produce documents that are relevant to the review. This notice will generally request documents relevant to the employment or engagement of practitioners by you during the review period. Subsequently, notices to produce may be issued for the production of clinical records relevant to the services under review to the Director.

If you have any queries about a notice to produce, please contact the PSR staff member nominated on the cover letter of the notice, who will assist you in providing the requested documentation. PSR strongly prefers that you produce electronic records, if possible, and will provide you with guidance materials to help facilitate this. PSR staff can also organise for a courier service to collect your records from you. Please note that there can be serious consequences for not complying with a notice to produce.

The Director will evaluate the clinical and other records provided to PSR. The Director may seek advice and assistance from consultants or professional bodies in relation to the review. Once the Director has considered the records and any consultancy advice, the Director (or another person on the Director’s behalf) may seek to meet with you in order to discuss the review. Please note that such a meeting is not a legislated formality, and may not be offered. It is also not mandatory to agree to such a meeting.

The meeting is intended to facilitate an exchange of information and assist the Director in making an informed decision. Your legal representative should be present during the meeting. At this meeting, the following may be discussed:

  • the nature of your employment arrangements with medical or healthcare practitioners who provide services under the MBS or PBS the Director’s preliminary views of the records that were provided to PSR (which will be outlined in a letter sent ahead of the meeting) and
  • any other matters relevant to the review, such as billing statistics of practitioners employed or engaged by you during the review period.

Following that meeting, if it appears to the Director that there are grounds on which a Committee of  peers could reasonably conclude that you engaged in inappropriate practice in providing services during the review period, the Director will send a report under section 89C of the Act. That report will give reasons why the Director has decided not to take no further action. It may raise issues such as:

  • compliance with regulatory requirements and professional expectations by practitioners employed or otherwise engaged by you
  • the quality and adequacy of records and other documentation
  • the clinical relevance of service provision
  • clinical input and decision making and
  • the extent to which any conduct of concern was knowingly, recklessly or negligently caused or permitted by you.

These issues will be discussed with reference to the conduct of practitioners in connection with the rendering or initiation of the MBS and/or PBS items under review. The Director will invite submissions in response to the report.

Any submissions that are provided will be carefully considered by the Director. The Director’s review of will then end in one of the following two ways:

  1. no further action
  2. referral to a committee

No further action

The Director will take no further action in relation to a review if satisfied that:

  1. there are insufficient grounds on which a Committee could reasonably find that you engaged in inappropriate practice in providing services during the review period or
  2. circumstances exist that would make a proper investigation by a Committee impossible.

The Director can make this decision at any stage during the Director’s review. If the Director makes a decision to take no further action, you and the Chief Executive Medicare will be informed of the decision and the reasons for it.

Referral to a Committee of peers

If after her review the Director considers that a Committee of peers could find that you engaged in inappropriate practice during the review period, the Director must establish a Committee of peers.

A referral to a Committee of peers involves establishing an independent decision-making body comprising:

  • a Chair; and
  • at least two members who are from professions or specialities relevant to the profession or specialities of the relevant practitioner/s engaged by you.

A Committee will follow formal statutory procedures. A Committee has broad information gathering powers, including powers to obtain evidence and hold a hearing. A Committee will ask questions of witnesses. This can include practitioners who personally rendered or initiated MBS or PBS services, as well as you, about the provision of MBS services and/or PBS medications.

Following the hearing, if a Committee decides to make preliminary findings of inappropriate practice, it will prepare an initial report (the ‘Draft Report’). This will set out the reasons for those findings and will discuss the relevant practitioner or practitioners’ conduct in connection with the services under review. Submissions from you will be invited in response to that report.

After considering any submissions provided by you, a Committee will then prepare its Final Report, setting out its findings of inappropriate practice. This is then referred to the Determining Authority. The Determining Authority will invite you to provide submissions and will then decide what directions to impose following a separate, staged process. Those directions can include repayment of Medicare benefits to the Commonwealth.

Note that if you are a practitioner (as well as an employer), directions can include your full or partial disqualification from the Medicare scheme for a specified period, or disqualification from the PBS for a specified period.