Review by the Director
The PSR process begins when a delegate of the Chief Executive Medicare requests the Director to undertake a review of your provision of services during a specified period (the review period). The Director must undertake a review if, after considering that request and any other relevant material, it appears that there is a possibility that you engaged in inappropriate practice (‘inappropriate practice’ is conduct in connection with rendering or initiating services that a Committee of peers could reasonably conclude was unacceptable to the general body of your profession or, if applicable, medical speciality).
Rendering a ‘prescribed pattern of services’ (which means rendering 80 or more professional attendance services on 20 or more days during a 12 month period) is also deemed to constitute inappropriate practice, except where this has occurred because of exceptional circumstances. The Director will obtain details of a random sample of your services that you billed or that relate to particular MBS and/or PBS items. The Director will then request medical records corresponding to this sample of services. Following a review of those records, the Director may seek to meet with you before preparing a report. You will have the opportunity to make submissions on this report.
The Director may decide to take no further action, may seek to enter into an agreement with you under section 92 of the Act (which needs to be ratified by the Determining Authority), or may refer you to a Committee.
Review by a Committee
The Director may establish a Committee, comprising a Deputy Director from your profession and at least two other practitioners from your profession or speciality (as applicable). Committee members are drawn from a panel appointed by the Minister. Like the Director, a Committee will examine a sample of services pertaining to particular MBS and/or PBS items. It will obtain medical records that are relevant to those services. If a Committee considers there is a possibility that you engaged in inappropriate practice, it will hold a hearing. During a hearing, a Committee will take your evidence on the services under review and any other relevant information.
After considering the evidence, if a Committee finds that you have not practised inappropriately, the matter is closed. If a Committee intends to make adverse findings that you have engaged in inappropriate practice, it will prepare a Draft Report. This report contains preliminary findings of inappropriate practice. You will be given an opportunity to provide submissions in response to the Draft Report. After considering any submissions, the Committee will prepare a Final Report detailing its findings of inappropriate practice. This is then provided to you, the Director and the Determining Authority.
The Determining Authority has two main functions, which are to:
- ratify Agreements reached between the Director of PSR and a practitioner and
- determine what actions should follow from a Committee’s finding of inappropriate practice.
More information about each of these stages can be found on the following pages.