Medicare cops reveal they unfairly prosecute healthcare providers


Medicare ‘cops’ reveal they have no consistent procedures or policies when prosecuting healthcare providers!

The Government has just admitted they do not provide authoritative guidelines .

We are concerned our Medicare Item Complexity has revealed Medicare audit anxiety may be harming patient care see Are uncertain Medicare rules hurting your provision of care?

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It is of serious concern that a powerful agency, one that demands the highest levels of accountability from the healthcare profession, has no such accountability itself when it executes its duty of care.

For example, look at this 2018 Freedom of Information Request.  We have been given exclusive access to this Freedom of Information on how providers are investigated for inappropriate billing in Australia. The Federal enforcement agency conducting these investigations is the Professional Services Review Committee, a statutory body.


Is this process of prosecution of providers a fair process? Or is it simply a money grab by the Government, based on questionable processes? The concern is that many professional lives are being ruined based on questionable evidence. This same concern was raised in a 2011 Federal Senate Inquiry into the PSR’s conduct. It appears nothing has changed since the Inquiry’s recommendations were made.

It is not just a matter of the investigated practitioner’s professional career. We believe this is harming patients’ access to care.

fair or unfair

There are concerning questions as to the role and due diligence of the PSR compliance process.

Is it fair and just?

The scope of the request is summarised below:


  1. There are no procedural fairness rules?!

item 3The FOI-obtained document clearly states they have no policy and procedures for electing panel members, or establishing criteria for prosecution, training or internal standards. Does this admission provide clear evidence that the due process that is constitutionally implied for statutory bodies may have been breached?

In other words, can anyone who has been subjected to PSR receive a fair hearing?

  1. There is no criteria or policy for the selection of panel members.


When there are no set criteria to follow, how then does the PSR enforce freedom from bias, and the appropriate skills and expertise of the panel members?

  1. What set key criteria are used to review a doctor’s performance?

a4How are meaningful, clinically-relevant assessments made, when there are no set or comparable criteria or data sets in use to demonstrate non-compliance when compared to one’s peers?

  1. What legal and clinical training is provided to prosecutors?a3

Given the seriousness and complexity of the prosecution process, it seems extraordinary that only one training meeting for panel members is held annually to cover a wide variety of issues, and there are no training policies or procedures in place for these panel members.

  1. No contract policy on hiring agency staff?

a2Once again, it seems extraordinary that a multi-million dollar agency that recouped $60 million in 2018 in inappropriate Medicare billing, has no policies or procedures or agreements in place for hiring independent consultants.

Practitioners should raise any concerns with their independent legal adviser and their professional association.

For more information contact us at Health and Life . Please note we are not lawyers. This information is a matter for public debate in the public interest we have raised this issue.

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