The Department of Health, Disability and Ageing has released a swathe of documents outlining how practitioners are flagged for review by the Medicare watchdog.
The Department of Health, Disability and Ageing has pulled back the curtain on how doctors land in the crosshairs of the Professional Services Review.
A new set of documents published by the department covers the specifics of how and when healthcare providers get selected to go before the PSR.
The most recent PSR director’s update, which covered the month of July 2025, revealed that GPs continued to make up a high portion of PSR cases.
Of the 16 cases finalised in that month, at least 11 were in relation to general practice.
Repayment orders for the 10 GPs who entered into a Section 92 agreement ranged between $106,000 and $700,000.
While the PSR investigates possible inappropriate use of the MBS and PBS, makes repayment orders and has the power to disqualify practitioners from billing Medicare, the independent statutory body is not responsible for the actual identification of those cases.
That duty falls to the DoHDA.
According to one newly released fact sheet, a set of qualified health professionals employed by the department regularly carry out “routine monitoring” of MBS billing and PBS prescribing practices to identify what it calls “possible inappropriate practice”.
“Data of medical practitioners in Australia, who bill under Medicare, is considered as part of the analysis to identify practitioners who are at variance to their peers,” the fact sheet read.
“Other relevant information is also considered, such as a practitioner’s location, patient profile/demographics, specialisation or special interests, additional training, clinical relevance, and other potentially relevant matters.”
Inappropriate practice is subject to some interpretation.
Another of the new fact sheets defines inappropriate practice as either unacceptable conduct, following a prescribed pattern of services or permitting inappropriate practice.
Unacceptable conduct itself is defined as conduct in connection with rendering or initiating an MBS service that a PSR committee “could reasonably conclude was unacceptable to the general body of the general body of their peers”.
Related
The DoHDA also receives tip-offs about suspicious billing practices.
Six of the most common issues associated with findings of inappropriate practice by the PSR, according to the department, include:
- MBS requirements not being met;
- Inadequate records;
- Insufficient clinical input;
- Not all services were clinically indicated;
- Patient consent was not adequately recorded; and
- Prescribing without appropriate clinical indication.
Documentation, it said, should be able to assist another practitioner to manage a patient’s condition, justify the service provided and, in the case of chronic disease management plans, be sufficiently individualised.
Examples of situations where MBS requirements were not always met included failing to collaborate with at least two other healthcare providers when billing an item 723 and rendering urgent after-hours services to patients who did not require urgent treatment.
