Practitioner Review Program

We review a practitioner's Medicare claims and Pharmaceutical Benefits Scheme (PBS) prescribing data to determine if their practice data differs from their peers and if it does, whether the difference may be due to inappropriate practice.

Inappropriate practice is conduct in connection with rendering or initiating services that a Professional Services Review committee could reasonably conclude would be unacceptable to the general body of that practitioner's professional peers - Health Insurance Act 1973.

For more information about inappropriate practice, go to section G.8.1 of the Medicare Benefits Schedule available from MBS Online on the Department of Health website.

What you need to know

There are 5 stages of the program but some steps may not apply to some reviews.

All stages of the Practitioner Review Program are carried out by registered health professionals employed by the department. You can contact the health professional at any time during the process.

Stage 1 - Initial contact

In the first instance, we will contact you to notify you of our concerns. We follow this up with a letter to you with a list of our concerns and relevant Medicare data.

If an interview is proposed, the letter will confirm the time and location.

When a general practitioner or 'other medical practitioner' has rendered a prescribed pattern of services breached the 80/20 rule, an interview will not be offered. The practitioner will be contacted by the delegated decision-maker (delegate) in writing in the first instance. The delegate is required by the Health Insurance Act 1973, to request the Director of Professional Services Review to review the practitioner's provision of services.

Stage 2 - Interview

The interview may be conducted either by phone, or face to face at an agreed convenient location. Our offices located across Australia are available if you would prefer not to have the interview at your practice.

At the interview, we talk with you about our concerns, and you have an opportunity to respond. There is no set format.

You can have a support person at the interview, but you will need to respond during discussions about our concerns rather than have a third party respond for you. You will need to tell us who else will be at the interview when arrangements for the interview are made.

Stage 3 - Post interview

A report of the interview will be compiled using information gathered from the interview. We will consider the information and advise you of the outcome.

Possible outcomes include the following:

  • all concerns are addressed - no further action is required and the matter is closed
  • some or all of the concerns remain – your profile will be reviewed again, usually after 6 months
  • the matter is considered by a delegate for assessment without a period of review

You can request a report of the interview. Read more about accessing information.

Stage 4 - Review

We will reassess your Medicare claims and Pharmaceutical Benefits Scheme prescribing data, including any new data from the period of review, and decide whether:

  • all concerns are addressed - no further action is required and the matter is closed
  • some or all of the concerns remain, or new concerns are identified - the matter will be considered by a delegate for assessment

We will write to you to let you know the outcome.

Stage 5 - Delegate assessment

Health professionals and senior staff employed by us have been delegated certain powers of the Chief Executive Medicare.

In particular, a delegate can make a request to the Director of Professional Services Review to review a practitioner's Medicare service provision and prescribing under the Pharmaceutical Benefits Scheme.

The delegate assesses all information at hand, including the report of the interview and relevant Medicare claims and Pharmaceutical Benefits Scheme prescribing data from the period of review post interview.

If the delegate considers that all concerns have been addressed, the matter is closed and you will be notified of the outcome.

If the delegate has remaining concerns or new concerns have arisen, the delegate will advise you in writing about the reasons for concern and invite you to provide a written submission. You will have 28 days to respond to an invitation for submission.

After consideration of the submission, the delegate will decide if either:

The delegate will write to you to let you know of the decision.

If you do not provide a submission, the delegate will make a decision about a request to the Director of Professional Services Review based on the available information.

Professional Services Review is an independent authority. Once the Director of Professional Services Review has been requested to review the provision of services by a practitioner, any further contact in regards to the matter will be directly between the Director of Professional Services Review and the practitioner.

Resources

Page last updated: 5 February 2016

This information was printed Tuesday 27 September 2016 from humanservices.gov.au/health-professionals/services/medicare/practitioner-review-program It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.