The Department of Health's concerns relate to a period of time over which you provided Medicare and/or PBS services (which must be within the previous two year period). This is referred to as the 'review period'.
PSR will examine your clinical records of the patients to whom you provided services during the review period and will determine whether or not you engaged in inappropriate practice in connection with those services. PSR does not have to confine itself to the services highlighted by the Department of Health. Matters PSR will take into consideration in determining whether you have engaged in inappropriate practice may include:
- whether your conduct when providing or initiating Medicare services would be unacceptable to the general body of your peers, including that you have
- not demonstrated the clinical relevance of the service
- not demonstrated that the service provided was clinically adequate
- failing to keep adequate and contemporaneous records. This can mean a number of things including that your records
- are illegible
- have inadequate detail to explain the condition and/or treatment
- do not demonstrate the clinical relevance of the service (i.e. that the service provided was clinically necessary or justified)
- whether your practice/conduct when prescribing or dispensing PBS medicines would be unacceptable to a body of your peers
- whether you have performed 80 or more professional attendance services on 20 or more days during a 12 month period without there being exceptional circumstances in relation to each of those days (for general practitioners or other medical practitioners rendering professional attendance services under the MBS)
- do not demonstrate that the requirements of the MBS or PBS were fulfilled.
During the PSR process, the Director and a PSR Committee may consider a range of documents or information as part of their review of your practice, including:
- the information within the Request to Review
- further statistical, claims related, information requested from the Department of Human Services (DHS)
- clinical records and other documents requested from you
- additional submissions you have provided to support your case
- clinical records and other documents from other practice locations at which you practised during the review period
- information provided by a consultant or learned professional body that the Director has contacted, in accordance with the Act, to obtain assistance in making his or her decision
- documents or oral evidence presented or given by yourself, your representatives or other witnesses throughout the PSR process.
PSR operates within a secure environment inaccessible to members of the public. All documents relating to a PSR matter are marked as confidential and locked in secure areas and IT systems that are encrypted and password protected in accordance with privacy and security requirements.
PSR employees are bound by secrecy provisions within the Health Insurance Act 1973 and the Australian Government's Information Privacy Principles set out in the Privacy Act 1988, the Crimes Act 1914 and the Public Service Act 1999 which contain offences for unauthorised disclosure of confidential information.