What happens if Medicare knocks on your door?
Medicare Australia administers Medicare and the Pharmaceutical Benefits Scheme. One aspect of that administration is to monitor and review the provision of services by medical practitioners to identify ‘inappropriate practice’.
Medicare issues doctors with statistics with respect to the services they provide in a calendar year. If Medicare identifies a medical practitioner who may be practising inappropriately as defined by the legislation, the practitioner may be invited to participate in Medicare’s Practitioners Review Programme (PRP).
Medicare may identify a doctor for the PRP in one of two ways:
- By identifying those doctors falling outside of the “average” medical practitioner by random sampling and running exception reports
- By responding to complaints made by patients or other service providers.
In November 2006, Medicare Australia revised its PRP from a two stage process to a one stage process. Any doctor identified by any of the processes mentioned above is asked to submit to an interview with a Medicare Australia medical advisor. This interview is an opportunity for the medical practitioner to discuss Medicare’s concerns. It is essential that the medical practitioner consider carefully the issues identified by Medicare and be able to justify and explain their practice and address the concerns at the interview.
Prior to undergoing the interview the medical practitioner will receive the data set which identifies the area of concern. This data set generally forms the basis of the interview.
Following the interview a report is prepared and the doctor is given access to the report to review and suggest changes.
Once the report is finalised it is considered by Medicare’s Case Management Committee who will make a decision which may include:
- Satisfaction with the doctor’s explanation and closure of the investigation
- Recommend a period of review which might be six or twelve months and on some occasions three months. If during or following the review period further concerns are raised or the original concerns have not been addressed the doctor may be given further opportunities to address the concerns. Ultimately, if Medicare Australia’s concerns remain then a formal report will be made to the Medical Director of the Professional Service Review at which time the doctor will be invited to provide written submissions.
The Professional Services Review is the last stage in the process and there are a number of sanctions which can be imposed which include:
- Repayment of Medicare benefits received (which can be substantial)
- A preclusion period for the doctor to claim Medicare benefits
- A disqualification of a doctor to claim Medicare benefits.
We recommend that you contact us if you are invited to attend an interview with a Medicare advisor to discuss issues regarding your prescribing or servicing of patients.
We are available to help you through that process to assist you to address Medicare Australia’s concerns.
By Anthony Mennillo
Claims and Legal Advisor
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