What you need to know
Stage 1 – Initial contact
Stage 2 – Interview
Stage 3 – Post interview
Stage 4 – Review
Stage 5 – Delegate assessment
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.
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.
- a list of concerns
- relevant Medicare servicing data
- the date, time and location of your interview, if you accepted our invitation
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.
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.
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
- 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
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 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:
- all concerns have been addressed and the matter is closed
- concerns remain and a review by the Director of Professional Services Review is required
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.
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
Health Professional Compliance
Health professional guidelines
Overview of the PBS