Practitioner Review Program overview
We assist in protecting Medicare, the Pharmaceutical Benefits Scheme (PBS) and Child Dental Benefits Scheme (CDBS) by reviewing practitioners and corporate entities where potential inappropriate practice is identified.
The PRP reviews Medicare servicing behaviour to determine whether to request a review by the Director of the Professional Services Review under the Professional Services Review (PSR) Scheme. Practitioners are only referred to the Director where concerns are unable to be resolved under the PRP.
Our process assesses a practitioner’s patterns of providing or initiating Medicare services or prescribing PBS items to identify practitioners who differ from their peers. This variance may indicate potential inappropriate practice.
Inappropriate practice relates to conduct by practitioners or corporate entities. It is detailed in section 82 of the Health Insurance Act 1973, and includes:
- Unacceptable conduct – rendering or initiating Medicare, PBS or CDBS services which a PSR Committee could reasonably conclude was unacceptable to the general body of a practitioner's peers. Practitioners may be reviewed through Practitioner Review Program – for practitioners where there are concerns of potential inappropriate practice.
- Prescribed pattern of services – rendering or initiating services by a practitioner during a particular period constituting a prescribed pattern of services, including:
- rendering or initiating 80 or more relevant services on each of 20 or more days in a 12-month period. This is known as ‘the 80/20 rule’.
- rendering or initiating 30 or more relevant phone services on each of 20 or more days in a 12-month period. This is known as ‘the 30/20 rule’.
- Causing or permitting inappropriate practice – knowingly, recklessly, or negligently causing or permitting a practitioner employed or otherwise engaged by the person 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.
How we conduct reviews
We employ qualified health professionals to conduct PRP reviews. A PRP review is not an indication of any wrongdoing or a judgement on the clinical care you provide your patients. It is the first step in understanding why your Medicare data differs from your peers.
If concerns cannot be resolved, 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 one year.
If the Chief Executive Medicare becomes aware of a breach of the 80/20 rule, a request to the Director must be made.
We acknowledge some practitioners may find the PRP process stressful. You may wish to seek support available through:
- professional bodies and other support services
- other health professionals
- colleagues, or support networks
- Medical defence organisations
- your professional indemnity insurer.
For more information about inappropriate practice, refer to the information provided below, visit PSR, MBS Online ,or refer to section 82 of the Health Insurance Act 1973.
- Inappropriate practice – Information about what inappropriate practice is, how it is identified and why it is important to conduct compliance on inappropriate practice, and commonly found compliance issues
- Inappropriate practice
- Our role in identifying possible inappropriate practice
- Common compliance issues associated with findings of inappropriate practice
- What to do to avoid practising inappropriately
- PRP for practitioners – Information about how the PRP is applied to practitioners, including
- what you need to know
- the PRP interview
- the PRP 6-month period of review
- referral to a delegate without a 6-month period of review
- delegate assessment
- Prescribed Pattern of Services (the 80/20 and 30/20 rules) – Information about the 80/20 and 30/20 rules including
- what you need to know
- how 80/20 and 30/20 breaches are detected and next steps
- exceptional circumstances
- 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.
- PRP for persons who employ or otherwise engage practitioners – Information about how the PRP is applied to a person (including an individual, a practitioner, a body corporate, and officer of a body corporate) who employs or otherwise engages practitioners.
- Health professional guidelines – Guidelines to help you understand what documents can be used to substantiate services if you are asked to participate in a compliance audit or review.
- Frequently asked questions – Frequently asked questions about the Practitioner Review Program.