OverviewThe PRP assists in protecting the integrity of the Commonwealth Medicare benefits, Dental benefits and Pharmaceutical benefits programs. The PRP process identifies and assesses anomalies in servicing data and, if appropriate, may result in a request to the Director of Professional Services Review (the Director) to review the provision of services.
Through the PRP, we consider Medicare servicing data, which is made up of Medicare claims and PBS prescribing data, to identify servicing practices that differ from peers. We then consider whether this may be due to inappropriate practice and whether a request to the Director should be made.
Inappropriate practice relates to conduct by practitioners that is defined in section 82 of the Health Insurance Act 1973, and refers to:
- Conduct of a practitioner in connection with rendering or initiating services for which a Medicare or Pharmaceutical benefit is or would be payable that would be unacceptable to the general body of that practitioner's professional peers. Practitioners in relation to whom there are concerns of unacceptable conduct may be reviewed through the Practitioner Review Program - for practitioners.
- Circumstances in which some or all of the services rendered or initiated by a practitioner during a particular period constitute a prescribed pattern of services (the rendering of 80 or more professional attendance services on each of 20 or more days in a 12 month period). This is commonly referred to as "the 80/20 rule".
- Circumstances where a person (including an individual, a practitioner, a body corporate, and officer of a body corporate), has knowingly, recklessly or negligently caused or permitted a practitioner employed or otherwise engaged by the person or body corporate of which they are an officer to engage in conduct that constitutes inappropriate practice.
The PRP process may result in a request being made by the Chief Executive Medicare or their delegate to the Director to review the relevant services over a period of up to two years from the date of the request.
If the Chief Executive Medicare becomes aware of a prescribed pattern of services, a request to the Director must be made.