Medicare (Australia) - Practitioner Review Programs

Practitioner Review Programs

This is a basic overview of the practitioner review process in point form:

• Medicare Australia provide a federal framework to deliver a health system to the people of Australia.
• Delivering health care to millions relies on proper utilisation of limited resources.
• As such, to make sure the services provided under the Medicare umbrella (including medicines administered by the PBS), reviews and audits are conducted.
• To quote the Medicare website, "identification and reviews of practitioners' practice profiles protect patients and the community from the risks and costs of inappropriate practice".
• Inappropriate practice is defined twofold:
  • "services that would be unacceptable to the general body of members".
  • includes the rendering of "80 or more professional attendances on each of 20 more days in a 12 month period", i.e. rorting the system through false services rendered.
• When practitioner is reviewed, their data is compared with that of their peers.
• If this data is markedly different than this practitioner may be referred to the Practitioner Review Program.
• If concerns still remain at the end of the Practitioner Review Program, then a referral to the Professional Services Review (PSR) can be made.
• The PSR:
  • Practitioners are always contacted by the PSR when a review concerning them is conducted.
  • Practitioners covered by the PSR include all who provide services within the PBS and/or Medicare framework (this includes doctors, dentists, allied health professionals).
  • The Medical Director of the PSR acts as a last-ditch arbitrator.
  • The Medical Director will compare the reported case to random data.
  • The outcome may be no further action, a reprimand (administered by the Determining Authority), counseling, etc.