The Practitioner Review Program (PRP) monitors Medicare servicing data and Pharmaceutical Benefits Scheme (PBS) prescribing data to identify and examine variations which may indicate possible inappropriate practice.
We assist in protecting the integrity of the National Medicare benefits, dental benefits and PBS by reviewing practitioners under the PRP. Our process identifies and assesses anomalies in servicing data and, if appropriate, may result in a request to the Director of Professional Services Review (the Director) to review the provision of services.
Inappropriate practice relates to conduct by practitioners or corporate entities that is defined in section 82 of the Health Insurance Act 1973, and refers to:
- Conduct of a practitioner in connection with rendering or initiating services for which a Medicare or Pharmaceutical benefit is or would be payable that would be unacceptable to the general body of that practitioner's professional peers. Practitioners in relation to whom there are concerns of unacceptable conduct may be reviewed through the Practitioner Review Program – for practitioners.
- Circumstances in which some or all of the services rendered or initiated by a practitioner during a particular period constitute a prescribed pattern of services (the rendering of 80 or more professional attendance services on each of 20 or more days in a 12 month period). This is commonly referred to as ‘the 80/20 rule’.
- Circumstances where a person (including an individual, a practitioner, a body corporate, and officer of a body corporate), has knowingly, recklessly or negligently caused or permitted a practitioner employed or otherwise engaged by the person or body corporate of which they are an officer to engage in conduct that constitutes inappropriate practice. These persons may be reviewed through the Practitioner Review Program – for persons who employ or otherwise engage practitioners.
The PRP process may result in a request being made by the Chief Executive Medicare ‘or their delegate’ to the Director to review the relevant services over a period of up to 2 years from the date of the request.
If the Chief Executive Medicare becomes aware of a prescribed pattern of services, a request to the Director must be made.
Review by a Department delegate without a period of review
In certain circumstances under the Practitioner Review Program, a period of review will not be offered, and the case will be considered by our delegated decision maker. A period of review will not be offered if you:
- fail to respond to our attempts to contact you
- decline to respond to our concerns
- do not want a period of review
- request a review by peers or the Director of Professional Services Review (at any time during the process)
- have undergone a period of review within the previous five years for the same concern
- have been found under the Professional Services Review scheme to have engaged in inappropriate practice in the previous five years
- have acknowledged you have engaged in inappropriate practice within the previous five years and signed a negotiated agreement with the Director of Professional Services Review
- have rendered a prescribed pattern of services which has breached the 80/20 rule.
Also a review will not be offered if there is a high level of concern about the nature or extent of possible inappropriate practice.
If you do not have a period of review, the delegate will consider the information available and determine if either:
- all concerns have been addressed, no further action is needed, and the matter will be closed
- some or all concerns remain, in which case you will be invited to provide a written submission to the delegate within 28 days.
- PRP for practitioners
Information about how the Practitioner Review Program (PRP) is applied to practitioners, who Medicare servicing data (inclusive of Medicare claims and PBS prescribing data) indicates possible inappropriate practice.
- PRP for persons who employ or otherwise engage practitioners
A person (including a practitioner) engages in appropriate practice if they knowingly, recklessly or negligently cause or permit a practitioner who they employ or otherwise engage, to engage in inappropriate practice. A 'person' includes an individual and a body corporate.
- Prescribed Pattern of Services (the 80/20 rule)
The 80/20 rule aims to address consistently high volumes of rendered services by general practitioners (GP) and other medical practitioners (OMP).
- Preparing a written submission for the PRP - for practitioners
As part of the Practitioner Review Program (PRP) you may be given an opportunity to provide a written submission or additional information relating to concerns about your claiming or prescribing.