Overview of a Committee’s review of your provision of services
The Director may establish a Committee of your peers to decide whether you engaged in inappropriate practice. The Director will send you a document that sets out the names of the practitioners who will comprise the Committee and the MBS and/or PBS items that are referred to the Committee for consideration. A report will set out the Director’s reasons for why he or she thinks you may have engaged in inappropriate practice.
You should engage a legal adviser if you have not already done so.
Panel Members and the appointment of a Committee
Committee members are drawn from a Panel of practising health or medical practitioners appointed by the Minister. Some Panel members are appointed as Deputy Directors.
A Committee includes a Deputy Director from your profession and two other Panel members who are from your profession or, if applicable, medical speciality. One or two more Panel members may also be appointed by the Director to give the Committee a wider range of clinical expertise.
You may challenge the appointment of a Committee member on the grounds of bias. The challenge must be made in writing to the Director within seven days of you receiving the copy of the referral. It must set out the basis on which the challenge is made. If the Director decides the challenge is justified, another member will be appointed to the Committee.
Once the Committee has been established, the Committee will decide which MBS and/or PBS items it will examine of those referred to it by the Director. The Committee will obtain patient records for a sample of services provided as each of those MBS and/or PBS items.
If you have the relevant records, a Notice to produce documents will be sent to you or your legal adviser specifying the documents you must produce.
As with the Director’s review, 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 for you to 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.
The records produced will generally be prepared in a PDF format with the progress notes and documents relating to the specific service or services under review electronically bookmarked for ease of reference during the Committee hearing. The same PDF version of the records will be provided to you and to each Committee member.
The Committee is required to hold a hearing if it appears that you may have engaged in inappropriate practice in providing the referred services.
Committee hearings are usually 4 to 6 days, but can be longer. Hearings are usually held in a tribunal room in your closest capital city. In most cases, hearings are held in blocks of two consecutive days at a time.
The Committee will decide upon suitable dates and provide an indication of those to you or your legal adviser. If any of the dates are impracticable for you, please contact PSR staff as soon as possible.
Prior to the hearing you will be sent a formal Notice of hearing, which will identify the hearing venue and dates of the hearing, and require you to attend and give evidence on those dates.
Attending the Hearing
A hearing is generally held from 9.30am–5.00pm. The Committee may adjourn throughout the day to confer and also to allow you to have a break from questioning. You may ask the Chair for a break at any stage.
The hearing is a closed hearing. Only the following people will attend:
- the Committee
- PSR staff to advise and assist the Committee
- a person recording the proceedings and
- you and any person(s) accompanying you, including your legal advisor.
It is important to note that failing to attend a hearing can result in serious consequences.
You are responsible for your costs associated with attending the hearing including travel and accommodation, if required.
During the Hearing
The Committee’s aim during the hearing is to:
- collect information to assist it in determining whether your conduct in connection with providing services would be unacceptable to the general body of your peers and
- give you an opportunity to respond to matters upon which the Committee may make a finding of inappropriate practice.
To do this, the Committee will consider your clinical decisions and input, whether the services you provided were necessary for the appropriate treatment of the patient, were justified and appropriate in light of the MBS item descriptor and/or PBS restrictions, and the adequacy of your medical records.
At the commencement of the hearing, the Chair will make an opening statement informing you of the structure of the hearing.
You will be invited to make any opening comments and tender any documents you would like the Committee to consider. The Committee will ask you general questions about your practice and experience, billing practices, record keeping and other matters. Then, the Committee will question you about specific services you have provided. Committee members may take turns questioning you.
The Committee hearing will be recorded and transcribed.
During the hearing you are entitled, subject to reasonable limitations or restrictions the Committee may impose, to:
- be accompanied by a lawyer or another adviser
- call witnesses to give evidence (other than evidence about your character)
- produce written character references
- question a person giving evidence at the hearing
- address the Committee on questions of law arising during the hearing
- make a final address to the Committee after the conclusion of the taking of evidence, on: questions of law, the conduct of the hearing, and the merits of the matters to which the hearing relates.
During the hearing, advisers accompanying you are entitled, subject to any reasonable limitations or restrictions the Committee may impose, to:
- provide you with advice
- if they are a legal adviser, address the Committee on questions of law that may arise
- after the conclusion of evidence being taken, make a final address to the Committee on questions of law (if they are a legal adviser), the conduct of the hearing, and the merits of the matters discussed during the hearing.
After the hearing is completed the Committee will consider the evidence and any final address, and produce a Draft Report.
The Committee’s Draft Report
If the Committee finds you have not practised inappropriately, your matter will be closed. Otherwise, the Committee’s Draft Report will outline its preliminary findings about each MBS or PBS service that involves inappropriate practice, along with the reasons for those findings. You have one month from the date that you receive the Draft Report to provide a written submission to the Committee.
If the Committee examined a random sample of services you rendered as a particular MBS item, the Committee can extrapolate findings of inappropriate practice to all of those particular MBS item services that you rendered during the review period.
Preparing your submission on the Committee’s Draft Report
The purpose of the written submissions is for you to suggest changes to the Draft Report. You may wish to submit to the Committee that it misunderstood or misevaluated the evidence in specific instances. It is important for you to consider the Committee’s specific findings in your response.
The Committee’s Final Report
After receiving submissions on the Draft Report, or if no submissions are received after a month, the Committee must prepare its Final Report.
The Committee will consider any submission that you make in preparing its Final Report.
The Committee cannot include a finding of inappropriate practice in the Final Report unless that finding was included in the Draft Report.
The Committee will send the Final Report to you and the Director. If the Final Report contains a finding of inappropriate practice, the Committee will send the Final Report to the Determining Authority one month later. The Determining Authority will then decide what outcome should follow from the Committee’s findings of inappropriate practice.
If the Committee finds that you did not engage in inappropriate practice it will provide a Final Report to you, the Director and Medicare, and no further action will be taken.