Practitioner Review Program

Information about how we review your Medicare servicing data to determine if it differs from your peers. If it does, we review whether the difference may be due to inappropriate practice.

Page last updated: 29 November 2016

Overview
What you need to know
Stage 1 – Initial contact
Stage 2 – Interview
Stage 3 – Post interview
Stage 4 – Review
Stage 5 – Delegate assessment
More information

Overview

We review your Medicare servicing data, which is made up of Medicare claims and Pharmaceutical Benefits Scheme (PBS) prescribing data, to determine if your practice data differs from your peers. If it does, we review 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.

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

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 professional advisers employed by us. You can contact the health professional adviser at any time during the process.

Stage 1 - Initial contact

We will contact you to notify you of our concerns and offer you the opportunity of an interview with one of our health professional advisers. We will then write to you with:
  • a list of concerns
  • relevant Medicare servicing data
  • the date, time and location of your interview, if you accepted our invitation
If you cannot commit to a date for the interview at the time of initial contact, you will need to call us back within 7 days to confirm the date for the interview.

If you do not make contact, or if you decline an interview, one of our health professional advisers will review your case based on the available information. An outcome of this may be to request a review by a delegate of the Chief Executive Medicare – refer to Stage 5.

An interview will not be offered if you have breached the 80/20 rule by rendering a prescribed pattern of services. A delegate of the Chief Executive Medicare is required by the Health Insurance Act 1973 to request the Director of Professional Services Review to review your provision of services – refer to Stage 5.

Stage 2 - Interview

The interview may be conducted either by phone or face to face at an agreed location. If you prefer not to have the interview at your practice, our offices are located in each major capital city.

There is no set format at the interview. We will discuss our concerns and you will have an opportunity to respond.

You can have a support person at the interview. When arrangements for the interview are made, you will need to tell us who else will be present.

Stage 3 - Post interview

We will consider the information gathered at your interview, compile a report and advise you of the outcome by letter. If you would like a copy of the report, please contact your health professional adviser.

Possible outcomes include the following:
  • all concerns are addressed and no further action is required, so the matter is closed
  • some or all of the concerns remain, meaning your Medicare servicing will be reviewed again, usually after 6 months
  • the matter is considered by a delegate of the Chief Executive Medicare without a period of review

Stage 4 - Review

We will review your Medicare servicing and include any new data from the period of review. We will then decide whether:
  • all concerns are addressed and no further action is required, so the matter is closed, or
  • some or all of the concerns remain, or new concerns are identified, and the matter will be considered by a delegate of the Chief Executive Medicare
We will write to you to let you know the outcome.

Stage 5 - Delegate assessment


Health professional advisers and senior staff employed by us have been delegated certain powers of the Chief Executive Medicare. These health professionals are called delegates of the Chief Executive Medicare.

A delegate can make a request to the Director of Professional Services Review to review your Medicare servicing.

The delegate reviews all current information at hand, which may include:
  • report of the interview and review
  • your Medicare servicing.
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 and invite you to provide a written submission. You will have 28 days to respond.

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. The Director of Professional Services Review may be requested to review your provision of services. In this instance, any further contact in regards to the matter will be directly between you and the Director of Professional Services Review.

More Information

MBS Online
Professional Services Review
Preparing a written submission for the Practitioner Review Program
Review by a Department delegate without a period of review
Prescribed Pattern of Services 80/20 rule
Health provider compliance audits and reviews
Medicare Billing Assurance Toolkit
Billing accurately under Medicare
Compliance for health professionals
Health professional guidelines
Overview of the PBS

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