Practitioner Review Program
The Practitioner Review Program (PRP) deals with practitioners whose provision of services under Medicare and/or PBS prescribing data suggests that there may be inappropriate practice.
Inappropriate practice (a) is defined as conduct in connection with rendering or initiating services that would be unacceptable to the general members of that profession.
The Practitioner Review Program has five stages.
Stage 1—Pre-interview
- From a practitioner’s practice profile data (b) Medicare Australia identifies that there may be inappropriate practice. This is usually based on differences to peers in their practice data. One special circumstance (c) is that a general or other medical practitioner is deemed to have practised inappropriately if he or she has rendered 80 or more professional attendances on each of 20 or more days in a 12 month period.
- A compliance medical officer (d) reviews the concerns and then contacts the practitioner to advise them of the concerns and arranges an interview.
- The interview date and time is confirmed by letter. The letter also lists the concerns and includes a data report of the practitioner’s servicing and prescribing for the period in question.
Stage 2—Interview
The interview with the practitioner occurs to discuss the concerns. There is no set format, and the interview provides an opportunity for the practitioner to respond to Medicare Australia’s concerns by providing information that may explain their servicing or prescribing.
Important: The practitioner can have another person present at the interview. However, the purpose of the interview is to discuss the concerns with the practitioner, rather than a third party.
Stage 3— Post interview
The compliance medical officer writes to the practitioner with the outcome of the interview which will either be:
- all the concerns have been addressed during the interview and no further action is necessary, or
- some or all of the concerns remain and the practitioner’s practice profile will be reviewed after a period of time—usually between 3 and 12 months— depending on the circumstances. The review period will be stated in the letter, or
- some or all of the concerns remain and in certain circumstances—such as a past adverse Professional Services Review finding—no review period will be offered and Medicare Australia’s delegate (e) will participate in the assessment of the concerns (stage 5).
Stage 4—Review
The review starts after the stated period expires and is completed within approximately three months. The practitioner’s practice profile data for the review period is analysed and if the compliance medical officer determines that:
- the concerns are addressed, then no further action is taken, or
- one or more concerns remain, then the practitioner is referred to Medicare Australia’s delegate for review.
The practitioner is informed in writing of the outcome of the review.
Stage 5—Medicare Australia delegate review
The delegate assesses the profile and if it is determined that:
- there is no concern, the referral is dismissed and the practitioner is informed in writing of the outcome, or
- if there are still concerns the practitioner will receive a letter inviting a written submission. This letter includes a data report and a statement of the concerns.
A determination or invitation for a written submission is usually confirmed within two months from the delegate receiving the referral. The time allowed for a written submission is 28 days.
If a written submission is received, Medicare Australia’s delegate reviews the submission and if it is determined that:
- the concerns have been addressed then no further action is taken. The practitioner is informed in writing of the outcome, or
- if concerns remain then the Director of Professional Services Review (DPSR)
, is requested to review the practitioner’s servicing. The practitioner receives a response to their submission (usually within four weeks) including formal notification of the request to the DPSR, along with a copy of the request.
If a written submission is not received, Medicare Australia’s delegate will consider the available information and either decide to take no further action or to request that the Director of Professional Services Review (DPSR) reviews the practitioner’s servicing.
Where there is a referral to DPSR, further communication about the review will come directly from DPSR.
A compliance medical officer manages the case from first contact to referral to the delegate (if required) and is available by phone to answer any inquiries. Medicare Australia’s delegates also provide a contact phone number at their first contact with the practitioner.
References
a. See MBS G.8.1 for more information about ‘inappropriate practice’
b. For Medicare Australia purposes, a practitioner's practice profile is a suite of Medicare and PBS data which reflect the services rendered (provided by or on behalf of the practitioner) or initiated (eg requests for pathology or diagnostic imaging) under Medicare and PBS prescribing for that practitioner over a specified time frame
c. See MBS G.8.1 for details of attendances covered by this provision.
d. A compliance Medical officer is a medical practitioner employed by Medicare Australia
e. Medicare Australia’s delegate for the purposes of Section 86 of the Health Insurance Act 1973 is a Senior Medical Adviser who has the delegation from the CEO to request the Director, PSR to review a practitioner’s provision of services.
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Last updated: 10 June, 2009