Practitioner Review Program
Medicare Australia is responsible for the administration of Medicare and the Pharmaceutical Benefits Scheme (PBS). As part of these responsibilities, Medicare Australia may request the Director of Professional Services Review (PSR) to review the provision of services by practitioners who are suspected of engaging in inappropriate practice under the Health Insurance Act 1973 (the Act).
Medicare Australia identifies practitioners where Medicare or PBS data indicates that their rendering, initiating or prescribing practice profile appears different when compared with their peers. While this may reflect the nature of the practice, it may also indicate inappropriate practice. Identification and reviews of practitioners’ practice profiles protect patients and the community from the risks and costs of inappropriate practice.
Inappropriate practice can be defined as:
- conduct in connection with rendering or initiating services that would be unacceptable to the general body of members of that profession; or
- knowingly, recklessly or negligently causing or permitting a practitioner employed by a person or body corporate to engage in conduct that would be unacceptable to the general body of members of that profession.
In addition, the Act specifies 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. General or other medical practitioner professional attendances include items A1, A2, A5, A6, A7, A9, A11, A13, A14, A15, A16, A17, A18, A19, A20, A21, A22 or A23 listed in the Medicare Benefits Schedule (MBS).
In determining whether a practitioner has engaged in inappropriate practice, regard is given to whether the practitioner has kept adequate and contemporaneous patient records.
The Practitioner Review Program consists of one or more of the following:
- an interview with one of Medicare Australia’s medical advisers or optometric advisers to discuss Medicare Australia’s concerns;
- a period of time to enable a practitioner to review their practice; and
- a review by Medicare Australia’s Medical Director to determine if a request should be made to the Director of PSR.
Requests to the Director of Professional Services Review
In considering making a request to the Director of PSR for review of a practitioner’s provision of services, Medicare Australia will take into consideration whether the:
- practitioner responds to Medicare Australia’s attempts to contact them;
- practitioner participates in an interview;
- practitioner asks Medicare Australia to request a review by the Director of PSR;
- practitioner addresses Medicare Australia’s concerns at the completion of a period of review and no new concerns have been identified;
- practitioner has previously undergone a period of review by Medicare Australia for the same concern; or
- practitioner has previously been determined by PSR to have engaged in inappropriate practice.
The practitioner will be provided with an opportunity to make a submission for consideration by Medicare Australia prior to a request being made to the Director of PSR. Following consideration Medicare Australia may decide that:
- Medicare Australia’s concerns have been addressed and the matter will be closed; or
- Medicare Australia’s concerns have not been addressed; and/or new concerns have been identified, in which that the Director of Professional Services Review will be requested to review the practitioner’s provision of services.
Further information
Case Studies
The following case studies are true accounts of investigations carried out by Medicare Australia under the Professional Services Review scheme. The cases have been re-identified to protect the privacy of the practitioner.
Introduction
Dr Dogood came to the attention of Medicare Australia in 2000 because over 90 per cent of her billed services were level D consultations. This placed Dr Dogood above the 99th percentile. To find out more about Dr Dogood's practice, Medicare Australia arranged for a medical adviser to visit her.
Background
Dr Dogood works eight sessions a week providing psychological services in a Brisbane inner city practice with seven general practitioners, two of them working full time.
Approximately two-thirds of Dr Dogood's patients are referred from other practitioners and range from seven years of age upwards. She routinely books 45 minute appointments for her counselling patients however they often go for longer.
Medicare Australia's review
A review of Medicare Australia's data showed:
- the majority of Dr Dogood's consultations are level D and all the parameters relating to level D consults are in the 97th to 99th percentile.
- no diagnostic imaging, pathology ordering or specialist referrals
- minimal prescribing with a total of only 130 original items and a gross PBS cost of about $8 500.
Analysis of age gender groups show that the majority of Dr Dogood's patients are aged 15 - 50 and that about two-thirds of the practice are female patients. The 15 - 50 age group brackets are all seen at a service per patient per year of 97th or greater percentile.
Dr Dogood explained that it was her usual practice to outline a course of treatment or therapy for her patients and this would take a number of sessions. A further review of Medicare Australia's data confirmed that for a majority of the patients there are episodes of treatment, which would typically be a consultation every week or fortnight over a period of two or three months with occasional subsequent visits.
Dr Dogood was very concerned that she appeared to be under investigation by Medicare Australia. She pointed out that she is a very experienced GP and has been involved in psychological medicine both as a provider and also through her professional associations. She has had a strong advocacy role for further general practice involvement in treating patients with psychological problems. Dr Dogood said that she was well aware of the legislative requirements for appropriate practice and clinical relevance and also of the need for adequate and contemporaneous notes.
The medical adviser explained there was no investigation of Dr Dogood. Medicare Australia's role is to monitor provider's data and where the data alone raised the possibility of inappropriate practice to arrange for a medical adviser to discuss the data with the provider.
Outcome
The medical adviser, having received this additional information from Dr Dogood, was able to make a more comprehensive evaluation of her practice. It was clear from the discussion with Dr Dogood that she had;
- significant experience, knowledge, training and qualifications in the specialised practice area of psychological medicine.
- Her profile of low pathology, radiology and prescribing was completely consistent with the offered explanation.
These factors, combined with her knowledge of the requirements as detailed in the MBS book, led the medical adviser to conclude that Dr Dogood's practice would almost certainly be acceptable to the general body of her peers, and it was therefore extremely unlikely that she was involved in inappropriate practice.
The medical adviser recommended no further action, and Medicare Australia accepted this advice. Dr Dogood continues to practice in the above locations, and has embraced the mental health item numbers, which she now uses where applicable.
Last updated: 28 May, 2008