EXPERTISE IN MEDICARE AUDITS AND REVIEWS

If you have received a letter from Medicare for the Professional Review Programme, or the Professional Services Review office, then you should seek appropriate legal advice. If your practice is to treat many patients under this programme, then advice as to compliance and the process of review is important.

Many indemnifiers will cover you for these interactions. Some will send a peer advisor or a lawyer. If you do not understand your obligations and if you are considered to not be compliant, then you need to get legal advice. Many advisors on these matters do not understand the process and the administrative nature of this jurisdiction.

If your advisors cannot answer your questions or do not seem to take the issues seriously – or possibly do not have a specialised knowledge of the law and relevant facts – then you may need independent advice. To respond effectively to these audits and reviews, you will need expert advice in regards to the law and the processes that are followed. Brad Wright has extensive experience with providing legal advice, legal representation and appearance in relation to Medicare and many other Health Insurance matters.

Please email info@dentalegal.com.au or call 07 3105 2811 for legal advice and an obligation free consultation. 

MEDICARE REVIEWS – SOME OBSERVATIONS

It is important to know and understand the powers of the PRP, PSR and the PSR Committee as well as the legislation as there are a number of Acts that are relevant. 

The most important one is a part of part VAA of the Health Insurance Act 1973 and this is called the Professional Services Review Scheme. 

The powers of the Practitioner Review Program are only whether to refer or not to the Director of Medicare or the Director of the Professional Services Review Scheme . 

Ultimately under section 80(10) if the Committee which has been formed by the Professional Services Review Scheme does indeed proceed to a hearing and if the Committee finds that the person under review has engaged in inappropriate practice, the finding will be reported to a determining authority. 

The determining authority is essentially a semi-permanent body of a medical practitioner and others who make decisions once a finding has been made of alleged inappropriate practice. 

Dental practitioners are covered under the Definitions and a definition of inappropriate practice is found at s 82 (2) and this provides that a practitioner engages in inappropriate practice if the person knowingly, recklessly or negligently causes or knowingly recklessly or negligently permits a practitioner employed or otherwise engaged by the person to engage in conduct that constitutes inappropriate practice by the practitioner under subsection (1) or (1A). 

Subsection (1) and (1)(a) of s 82 provides that a practitioner engages in inappropriate practice if the practitioner’s conduct in connection with rendering or initiating services is such that a committee could reasonably conclude that (d) if the practitioner who rendered or initiated the services is neither a general practitioner nor a specialist but as a member of a particular profession – the dental profession-  the conduct would be unacceptable to the general body of the members of that profession.

Section 82(1)(a) provides that inappropriate practice can consist of rendering or initiating services during a particular period if the circumstances in which all or some of the services were rendered or initiated constitute a prescribed pattern of services.  

Section  82(2)(b) provides that if a practitioner is an officer of a body corporate and knowingly, recklessly or negligently causes, or knowingly, recklessly or negligently permits, a practitioner employed by the body corporate to engage in conduct that constitutes inappropriate practice by the practitioner under subsection (1) and (1)(a) then this can be inappropriate practice.

Section 82(3) provides that a Committee must, in determining whether a practitioner’s conduct in connection with rendering or initiating services was inappropriate practice, have regard to (as well as to other relevant matters) whether or not the practitioner kept adequate and contemporaneous records of the rendering or initiation of the services. 

There are a number of procedural aspects to how a committee might proceed but most importantly in considering its final determinations which are provided for at s 106U of the Health Insurance Act 1973, they can, put simply, reprimand, counsel, make payments, cease payments to be made, repay amounts to the Commonwealth, be disqualified from the provision of services in relation to certain services or could be fully disqualified for a specified period from receiving Medicare benefits and dental benefits in relation to services rendered or initiated by a practitioner. 

Under s 106(X)(b) of the Health Insurance Act 1973, if in the course of the performance of functions or the exercise of powers under this Part, a Committee or the Determining Authority forms the opinion that a practitioner has failed to comply with professional standards, the Committee or the Authority must give to the Director a written statement of its concerns, together with the material on which its opinion was based and if the Director or the Determining Authority provides material upon which the Director forms an opinion that the practitioner has failed to comply with professional standards or receives advice from the Committee or the Determining Authority then the Director must prepare a statement of concerns and send it to the appropriate body which is the Dental Board of Australia (DBA) or send the Statement from the Committee or Authority to the DBA.