What you need to knowUnder the Health Insurance Act 1973, 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 of which they are an officer, 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, a delegate of the Chief Executive Medicare (delegate) will review the matter.
A delegate is an officer employed by the Department of Health (the Department) who has been delegated certain powers of the Chief Executive Medicare, including the power to make a request to the Director of Professional Services Review (the Director) to review the provision of services during a specified period.
The delegate considers the information before him or her and decides 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 officer1.
Stage 1 – Notification and request for written submissionsThe delegate will write to you to let you know that your provision of services is under review and provide you with an outline of their concerns.
You will be offered an opportunity to provide additional information through a written submission. You will have 28 days to respond.
In your written submission you may provide us with any additional information to assist our 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 assessmentTwenty eight (28) days after the notification period has ended, the delegate reviews all relevant information at hand, which may include:
- information about and comments made by practitioners employed or otherwise engaged by the relevant person or by a body corporate
- Medicare servicing data
- information provided in your written submission.
The delegate will write to you to let you know of the outcome. Where a request is made to the Director, the delegate will give you written notice of this within 7 days after the request being made.
If 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 1973 to request the Director to review your provision of services.
A request to the Director is the initial step in the process for reviewing the provision of professional services under the Health Insurance Act 1973. It 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.
1 Health Insurance Act 1973, subsection 81(2).