Practitioner Review Program – for practitioners

Information about how the Practitioner Review Program (PRP) is applied to practitioners, whose Medicare servicing data (inclusive of Medicare claims and PBS prescribing data) is different to that of their peers, to assess whether this may be indicative of possible inappropriate practice.

Page last updated: 05 July 2018

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

What you need to know

The PRP is a multi-staged process that involves professional advisers conducting a review of your Medicare servicing data, assessing differences from that of your peers and considering whether such differences may be indicative of possible inappropriate practice, and whether a request should be made to the Director of Professional Services Review (the Director) to review your provision of services.

There are five stages of the PRP for practitioners; however some stages may not apply to some reviews.

All stages of the PRP are carried out by registered health professional advisers employed by the Department of Health (the Department). If you have questions throughout the PRP process you can contact the health professional adviser at any time.

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; and
  • an invitation to attend an interview and the proposed date, time and location.
If you cannot commit to a date for the interview at the time of initial contact, you will need to contact us within 7 days to confirm a date for the interview.

You are not required to attend the interview or to provide us with any additional information if you do not wish to do so. If you do not respond to our initial contact, or if you decline an interview, one of our health professional advisers will rely on the available information to assess your case. An outcome of this may be to refer the matter to a delegate of the Chief Executive Medicare to consider whether to make a request to the Director – see Stage 5.

If you have breached the 80/20 rule by rendering or initiating a prescribed pattern of services, the Department will contact you, usually by phone, to confirm your details and notify you that your servicing data will be referred to a delegate of the Chief Executive Medicare for review.

You will not be offered an interview or a period of a review. In such circumstances, a delegate of the Chief Executive Medicare is required by the Health Insurance Act 1973 to request the Director to review your provision of services. As such, your case will proceed directly 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 with you and you will have an opportunity to provide us with additional information.

You can attend the interview with a support person. 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. You can request a copy of the report from your health professional adviser.

Possible outcomes include the following:

Stage 4 - Review

We will review your Medicare servicing data and include any new data from the period of review, as determined following Stage 3. Possible outcomes include the following:
  • 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 is referred to a delegate of the Chief Executive Medicare to consider whether to make a request to the Director - see stage 5.
We will write to you to let you know the outcome.

Stage 5 - Delegate assessment

Health professional advisers and senior staff employed by the Department have been delegated certain powers of the Chief Executive Medicare, including the power to make a request to the Director to review the provision of services by a person during a specified period. These officers are called delegates of the Chief Executive Medicare (delegates).

At this Stage, the delegate reviews all relevant information at hand, which may include:
  • the report of the interview and review, if these steps occurred and
  • your Medicare servicing data.
If the delegate considers that a request should not be made to the Director, the matter will be closed and you will be notified of the outcome.

If the delegate has remaining concerns or new concerns have arisen that the delegate considers may warrant a request to the Director, the delegate will advise you of this in writing and invite you to provide a written submission with any further information. In the case of a breach of the 80/20 rule, you should provide information that relates to the accuracy of your medical servicing data held by the Department. You will have 28 days to respond.

If you do not provide a submission, the delegate will make a decision about whether to make a request to the Director based on the available relevant information.

After consideration of any submissions received, the delegate may: The delegate will write to you to let you know of the decision. Where a request is made to the Director, the delegate will give you written notice of this within 7 days after the request being made.

If you have breached the 80/20 rule by rendering or initiating a prescribed pattern of services, the delegate is required by the Health Insurance Act 1973 to request the Director to review your provision of services.

If a review by the Director is requested, the delegate will provide the Director with the reasons for the request and information relating to the provision of services which are the subject of the request. This may include Medicare servicing data, prescribing data and any other information provided by you at interview and/or in your submission.

A request to the Director is the initial step in the process for reviewing the provision of professional services under the Health Insurance Act 1973. It is not a final or determinative decision regarding whether inappropriate practice has occurred. Following a request, the Professional Services Review (PSR) will proceed in accordance with the statutory process, which includes opportunities at various stages for you to be informed of relevant information about your case and make submissions.

PSR is an independent authority. If a request is made to the Director to review your provision of services, any further contact in regards to the matter will be directly between you and the PSR.

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
Health Professional Compliance
Health professional guidelines
Overview of the PBS

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