What you need to knowUnder the Health Insurance Act 1973 (Health Insurance Act), a person (including a practitioner) engages in inappropriate 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.
Additionally, an officer of a body corporate engages in inappropriate practice if they knowingly, recklessly or negligently cause or permit a practitioner employed or otherwise engaged by the body corporate, to engage in inappropriate practice.
If there is a concern that a person, including an officer of a body corporate, has caused or permitted inappropriate practice, the Chief Executive Medicare will review the matter and may make a request under subsection 86(1) of the Health Insurance Act to the Director of Professional Services Review (the Director) to review the provision of services during a specified period. The Chief Executive Medicare has delegated his or her powers to certain delegates (delegates), who are officers of the Department of Health.
The delegate will consider the information before him or her and decide whether to make a request to the Director to review the provision of services. Provision of services in this context includes services that are rendered or initiated by a practitioner employed or otherwise engaged by the person, or employed or otherwise engaged by a body corporate of which the person is an officer.
There are three streams under which persons who employ or otherwise engage practitioners may progress through the Practitioner Review Program. In each case, the delegate will determine whether there is sufficient evidence and information available that would require or allow the delegate to make a request to the Director to review the provision of services.
Stream 1 – Sufficient Evidence and Information available to the delegateIf the delegate is satisfied there is sufficient information and evidence available to him or her to make a request to the Director, the delegate will make a request to the Director to review your provision of services during a specified period. The information available to the delegate may include:
- information about and comments made by practitioners employed or otherwise engaged by the relevant person; and
- Medicare servicing data.
Stream 2 – Insufficient Evidence and Information available to the delegate
Stage 1 – Notification and request for written submissionsIf the delegate is not satisfied there is sufficient information and evidence available to him or her, the delegate may write to you with an outline of his or her concerns regarding your provision of services. The delegate will offer you an opportunity to provide additional information through a written submission. Generally, you will have 28 days to respond.
In your written submission you may provide any additional information to assist the delegate’s understanding of your provision of services and whether inappropriate practice may have occurred. For example, you may wish to provide documents that set out relevant policies, procedures or training programs.
Providing a written submission is optional. You are not required to make a written submission or to provide any additional information if you do not wish to do so. 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.
Stage 2 - Delegate assessmentAfter the period for providing submissions, the delegate will review all relevant information, which may include:
- information about and comments made by practitioners employed or otherwise engaged by the relevant person;
- Medicare servicing data; and
- information provided in your written submission.
Stream 3 – 80/20 RuleIf 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 to request the Director to review your provision of services.
Where a request is made to the DirectorWhere the delegate makes a request to the Director, the delegate will give you written notice of this within 7 days of the request being made.
A request to the Director is the initial step in the process for reviewing the provision of professional services under the Health Insurance Act. A request to the Director 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.