Medicare Benefits Schedule - Note AN.0.18

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Category 1 - PROFESSIONAL ATTENDANCES

AN.0.18

Provision for Review of Practitioner Behaviour

Professional Services Review (PSR) Scheme

The Professional Services Review (PSR) Scheme is a scheme for reviewing and investigating the provision of services by a health practitioner to determine whether the practitioner has engaged in inappropriate practice in the rendering or initiating of Medicare services or in prescribing under the Pharmaceutical Benefits Scheme (PBS). 'Practitioner' is defined in Section 81 of the Health Insurance Act 1973 and includes: medical practitioners, dentists, optometrists, chiropractors, midwives, nurse practitioners, physiotherapists, podiatrists and osteopaths. 

Section 82 of the Health Insurance Act 1973 defines inappropriate practice as conduct that is such that a PSR Committee could reasonably conclude that it would be unacceptable to the general body of the members of the profession in which the practitioner was practising when he or she rendered or initiated the services.  It is also an offence under Section 82 for a person who is an officer of a body corporate to knowingly, recklessly or negligently cause or permit a practitioner employed by the person to engage in such conduct. 

The Department of Human Services monitors health practitioners' claiming patterns. Where an anomaly is detected, for which a satisfactory explanation cannot be provided, the Department of Human Services can request that the Director of PSR review the provision of services by the practitioner.  On receiving the request, the Director must decide whether to conduct a review and in which manner the review will be conducted.  The Director is authorised to require that documents and information be provided. 

Following a review, the Director must:

(a)              decide to take no further action; or

(b)              enter into an agreement with the person under review (which must then be ratified by an independent Determining Authority); or

(c)              refer the matter to a PSR Committee. 

A PSR Committee consists of the Chairperson and two other panel members who must be members of the same profession as the practitioner under review. However, up to two additional Committee members may be appointed to provide a wider range of clinical expertise. 

The Committee is authorised to:

(a)              investigate any aspect of the provision of the referred services, and without being limited by the reasons given in the review request or by a Director's report following the review;

(b)              hold hearings and require the person under review to attend and give evidence; and

(c)              require the production of documents (including clinical notes). 

A PSR Committee may not make a finding of inappropriate practice unless it has given the person under review notice of its intention to review them, the reasons for its findings, and an opportunity to respond.  In reaching their decision, a PSR Committee is required to consider whether or not the practitioner has kept adequate and contemporaneous patient records.  It will be up to the peer judgement of the PSR Committee to decide if a practitioner's records meet the prescribed standards. 

The standards which determine if a record is adequate and contemporaneous are prescribed in the Health Insurance (Professional Services Review) Regulations 1999

To be adequate, the patient or clinical record needs to:

­                  clearly identify the name of the patient; and

­                  contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated; and

­                  each entry needs to provide clinical information adequate to explain the type of service rendered or initiated;              and

­                  each entry needs to be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient's ongoing care. 

To be contemporaneous, the patient or clinical record should be completed at the time that the service was rendered or initiated or as soon as practicable afterwards.  Records for hospital patients are usually kept by the hospital and the practitioner could rely on these records to document in-patient care. 

The practitioner under review is permitted to make submissions to the PSR Committee before key decisions or a final report is made. 

If a PSR Committee finds that the person under review has engaged in inappropriate practice, the findings will be reported to the Determining Authority to decide what action should be taken:

(i)               a reprimand;

(ii)              counselling;

(iii)             repayment of Medicare benefits; and/or

(iv)             complete or partial disqualification from Medicare benefit arrangements for up to three years. 

Further information on the Professional Services Review is available at www.psr.gov.au and information on  Medicare compliance is available at http://www.humanservices.gov.au/health-professionals/subjects/compliance?utm_id=9

Penalties

Penalties of up to $10,000 or imprisonment for up to five years, or both may be imposed on any person who makes a statement (either orally or in writing) or who issues or presents a document that is false or misleading in a material particular and which is capable of being used with a claim for benefits. In addition, any practitioner who is found guilty of such offences shall be subject to examination by a Medicare Participation Review Committee (MPRC) and may be counselled or reprimanded or may have services wholly or partially disqualified from the Medicare benefit arrangements. 

A penalty of up to $1,000 or imprisonment for up to three months, or both, may be imposed on any person who obtains a patient's signature on an assignment of benefit form without necessary details having been entered on the form before the patient signs or who fails to cause a patient to be given a copy of the completed form. 

Medicare Participation Review Committee (MPRC)

The Medicare Participation Review Committee determines what administrative action should be taken against a practitioner who:

(a)        has been successfully prosecuted for relevant criminal offences; or

(b)        has been found to have engaged in inappropriate practice under the Professional Services Review scheme.  

The Committee can take no further action, counsel or reprimand the practitioner, or determine that the practitioner be disqualified from Medicare for a particular period or in relation to particular services for up to five years. 

Medicare benefits are not payable in respect of services rendered by a practitioner who has been fully disqualified, or partly disqualified in relation to relevant services under the Health Insurance Act 1973 (Section 19B applies).


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change