What's new?

May 2013

The Healthcare Identifiers Service Licensed Materials for the May 2013 release are now available.

January 2013

New eligibility requirements for the PIP eHealth Incentive start 1 February.

The Department of Human Services’ Compliance Program 2012—13 is now available.

The 2013 Medicare Teen Dental Plan voucher is valued up to $166.15

The Medicare Safety Net threshold figures for 2013 are now available.

Practitioner Review Program

 Under the Practitioner Review Program (PRP) the Department of Human Services (the department) reviews the activities of health practitioners whose Medicare claiming and/or PBS prescribing data indicate they may be practising inappropriately.

The department reviews a practitioner’s practice profile data to determine if their practice data differs from their peers and if it does, whether the difference may be due to inappropriate practice.

Inappropriate practice is defined as conduct in connection with rendering or initiating services that a Professional Services Review committee could reasonably conclude would be unacceptable to the general body of that practitioner’s professional peers. (Health Insurance Act)

For more information about inappropriate practice go to section G.8.1 of the Medicare Benefits Schedule.

There are 5 stages of this program and some may not apply depending upon the review outcomes:

Stage 1—Pre-interview

  • We will contact the practitioner to notify them of our concerns and arrange an interview.
  • We will send a letter to the practitioner advising the interview date and time, and will include our concerns and the relevant data.

Stage 2—Interview

We will talk to the practitioner about our concerns. There is no set format, and the interview gives the practitioner an opportunity to respond to these concerns.

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

We will provide the practitioner with a copy of a report of the interview. They will be given 14 days to correct any factual errors within the report.

Once we have considered comments made at the interview and any corrections to the report of interview, we will let the practitioner know the outcome.

There are 3 possible outcomes.

    1.  no further action if all concerns were addressed during the interview, or
    2. a review period is scheduled, usually from three to 12 months depending on the circumstances. This is where some or all of the concerns remain unaddressed, or
    3. a delegate assessment is needed.

Stage 4—Review

We will reassess the practice data, including any new data from the review period, and decide whether:

  • no further action is required as all concerns have been addressed, or
  • one or more concerns remain or new concerns are identified. If so, we will ask our delegate to assess the data and information provided at interview.

In each instance, we will write to the practitioner to let them know the outcome of each review.

Stage 5—Delegate assessment

Our delegate assesses the report of interview, the outcomes of the interview and the practitioner's practice profile data, which will include any data from the review period. The delegate can dismiss the concerns or invite the practitioner to provide a submission. The practitioner has 28 days to respond, depending on the circumstances.

Once our delegate receives the submission, they can determine if the concerns have been addressed or if a review by the Director of Professional Services Review (DPSR) is needed.External link

We will write to the practitioner to let them know of our delegate's decision.

If the practitioner does not provide a submission, we will request the DPSR to review the practitioner's services.

If the case is referred to the DPSR, they will contact the practitioner directly.

Professional Advisers

A professional adviser manages Stages 1 to 4 of the Program and conducts the interview. The practitioner can contact the professional adviser at any stage. 

The delegate role is currently undertaken by Senior Medical Advisers who can also be directly contacted in Stage 5.

For more information

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Last updated: 4 March, 2013