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Health Insurance Commission

The Health Insurance Commission (hereinafter referred to as "HIC") administers Medicare and refers alleged cases of inappropriate practice to the Director of Professional Services Review (herein after referred to as "PSR") for investigation.

`Inappropriate practice' means professional conduct that a committee of the practitioner's peers would reasonably consider unacceptable to the general body of the peer group.

The PSR Scheme authorises examination of health practitioners' conduct to ascertain whether or not they have practised inappropriately in relation to services which attract Medicare rebates or have prescribed inappropriately under the Pharmaceutical Benefits Scheme.

Health Practitioners are defined under the Act to include medical and dental practitioners, optometrists, chiropractors, physiotherapists and podiatrists.

Before referral to the Director, the HIC usually offers the practitioner under review counselling and the opportunity to rectify the situation before formal action is initiated.

A Medical Adviser from the Professional Review Branch will usually write to a Practitioner to arrange a meeting for the purposes of the Professional Services Review Scheme. The meeting is usually held at the Practitioner's Surgery.

The purpose of the meeting is to resolve the concerns of the HIC in relation to the Practitioner.

The concerns may relate to;-

1. a high volume of daily services;
2. a high volume of total services;
3. a high level of pathology services ordered;
4. a high number of particular procedures.

Subsequent to the meeting the Practitioner is provided with a report. The report usually deals with;-

1. the Practitioner's background and the style of practice being conducted.;
2. if a high volume of total services is an issue, then the practitioner will be advised of the total number of services provided in a twelve month period and how that compares with a comparison peer group;
3. if a high volume of daily services is an issue, then the Practitioner will be advised of the 80/20 deeming provision of the 1999 Health Insurance Amendment Regulations which provides that if a Practitioner performs 80 or more services on 20 or more days in a 12 month period then the Practitioner will be deemed to have practiced inappropriately unless exceptional circumstances apply.
4. if a high level of pathology services ordered is an issue then the Practitioner will be shown his provider summary statistics for the twelve month period;
5. if the Practitioner is unable to provide a satisfactory explanation in relation to each issue then a change in the conduct of the practice may be recommended.

The State Case Management Committee will usually review a Practitioner's Statistics six months after the report issues. If recommended changes in the conduct of the practice are not reflected in the Statistics, then an Investigative Referral may issue.

In the next stage, the HIC prepares an Investigative Referral to the Director. A copy is sent to the Practitioner, with an invitation to make a written submission to the Director within 14 days.

The Director may appoint case officers to investigate the referral. They may inquire into services not included in the HIC's reason for referral. The Director has the power to require documents to be produced: there are penalties for non-compliance. After an investigation, the Director may;-

• dismiss a referral;
• negotiate an agreement; or
• establish a PSRC.

The Director may dismiss a referral if satisfied that the Professional Services Review Panel ( hereinafter referred to as "PSRP") would not make a finding of inappropriate practice.

In the event that the Director establishes a PSRC then the Secretary of the Committee will write to the Practitioner enclosing a Notice of Hearing which requires the Practitioner to appear and to give evidence.

The Practitioner will be invited to provide to the Committee a copy of any submission made by the Practitioner to the Director together with any written material relating to exceptional circumstances.

The Practitioner may produce evidence, call witnesses and be accompanied to the hearing by a lawyer. The lawyer can;-

• advise the person under review;
• address the committee on questions of law;
• make a final address to the committee on questions of law, the conduct of the hearing and the merits of the maters to which the hearing relates.

The Committee will have its own legal advisor present during the hearing.

The PSRP consists of medical practitioners appointed by the Minister after consultation with the AMA; and of dentists, optometrists, chiropractors, physiotherapists and podiatrists appointed by the Minister after consultation with appropriate professional organisations. From the Panel, the Minister appoints Deputy Directors, who chair the Committees.

A Professional Services Review Committee ( herein after referred to as "PSRC") consists of a Deputy Director and generally two other Panel members from the same peer group or profession as the Practitioner under review. Where the Director considers it desirable to give the Committee a wider range of clinical expertise, up to two more Panel members may be included.

The Determining Authority comprises a medical practitioner as Chair, a lay person and a member of the relevant profession. Members are appointed by the Minister following consultation with the appropriate profession.

A Medicare Participation Review Committee ( hereinafter referred to as "MPRC") can disqualify the practitioner, against whom two adverse determinations have been made, from the Medicare program for up to five years.

The Federal Court can, at any stage in the process, hear applications and appeals from Practitioners.