Stage 1: PSR Director reviews the information

The PSR process begins when a delegate of the Chief Executive Medicare asks the PSR Director to review services you provided during a specified period.

The Director considers the request and any other relevant material. If it appears to the Director that there is a possibility that you engaged in inappropriate practice, they must do a review, focusing on:

your provision of MBS or CDBS services
your prescribing of PBS medicines (if relevant)
any other issues that may arise.

Conducting a review

The PSR Director’s review will usually follow these steps:

Who	What
Director	notifies you and the Chief Executive Medicare that they have decided to do a review sends you a form with questions about your practice during the review period
You	fill out the form and return it to the PSR staff member listed in your letter
Director	obtains details of a sample of services billed in your name that relate to particular MBS, PBS and CDBS items sends you (and/or a third party (or parties)) a notice to produce patient clinical records or other documents advises you how to submit the records electronically or by courier informs you there can be serious consequences if you do not comply with the notice
You	provide electronic records (we strongly prefer this) or ask us for help to send by courier contact the PSR staff member listed on the cover letter if you have any questions about this notice
Director	evaluates your data and records may seek advice from consultants or professional bodies
Director (or a person acting on their behalf)	may meet with you to talk about the review (this is not a legal requirement so we may not offer a meeting, and if we do, you do not have to agree to it)

If you and the Director decide to meet, PSR then follows these steps:

Who	What
Director (or a person acting on their behalf)	sends you a letter outlining the preliminary views of the relevant materials reviewed
You	may arrange to hold the meeting at your practice or your legal representative’s office can have your legal representative or a support person from your medical defence organisation (or equivalent) with you
You, your legal representative, Director (or a person acting on their behalf)	meet and discuss the matters raised in the letter you received to help the Director make an informed decision, including: your practice, background and training the preliminary views of your records any other relevant matters, such as your billing statistics.

Preparing a report

If it appears to the Director that your peers could reasonably conclude that you engaged in inappropriate practice, the next steps are:

Who	What
Director	sends you a report under section 89C of the Act, explaining the reasons for issuing the report, including: your compliance with regulatory requirements and professional expectations the quality and adequacy of your records and other documents the clinical relevance of your service provision your clinical input and decision-making Invites you to submit a response
You	make a submission in response to the section 89C report carefully considers your submission
Director	decides on one of the following options: to take no further action (dismiss the matter) to negotiate an agreement with you under section 92 of the Act to refer you to a peer review Committee

Deciding on the outcome

Option 1: Dismissing the matter

The Director will take no further action if they are satisfied that either:

there are insufficient grounds for a Committee to reasonably find that you engaged in inappropriate practice
there are circumstances that would make it impossible for a Committee to conduct a proper investigation.

The Director can decide to take no further action at any stage during their review. If they do, they will inform you and the Chief Executive Medicare, including the reasons for this.

Option 2: Negotiating an agreement

If the Director considers that a Committee of your peers could find that you engaged in inappropriate practice, they may decide to try to resolve the matter by negotiating a section 92 agreement with you.

The agreement will:

require you to acknowledge that you have engaged in inappropriate practice
include specified actions, such as repaying benefits relating to specific services, a period of partial or full disqualification from the MBS, PBS or CDBS, or a reprimand from the Director.

For a section 92 agreement to take effect, it must be ratified by the Determining Authority. See Stage 3.

If you and the Director cannot agree on the terms of a section 92 agreement, the Director will usually refer your case to a PSR Committee (see Stage 2). If that occurs, the Director can no longer make an agreement with you.

Option 3: Referring to a committee

If the Director refers your case to a PSR Committee, it will determine whether you engaged in inappropriate practice during the review period. It may require you to produce documents and appear and give evidence at a hearing.

The Director prepares a report and sends it the Committee with their referral. The Committee’s investigation is not limited to either:

the reasons contained in the Director’s report
Medicare’s initial request to review your provision of services.

The Committee is not told about any negotiations between you and the Director about a section 92 agreement. The Committee process is described in detail in Stage 2.