In Australia’s public health system, we’re fortunate to have access to Medicare and the PBS, enabling equitable access to healthcare and life-saving treatments. But with this access comes responsibility—and for doctors, that includes ensuring our billing practices meet the expectations of both the law and our peers.
The Professional Services Review (PSR) exists to uphold those standards, and while it’s rare for an anaesthetist or intensivist to find themselves under review, it’s important to know how the system works—and what to avoid.
What is the PSR?
The Professional Services Review is an independent agency that investigates Medicare and PBS billing by practitioners when there are concerns about inappropriate practice. This doesn’t necessarily mean fraud or misconduct. Rather, it refers to conduct that your peers might consider unacceptable—for instance, billing for services that weren’t clinically indicated, weren’t properly documented, or weren’t even performed in person.
As anaesthetists and ICU doctors, we’re not immune. Even seemingly minor errors—like inadequate documentation or misapplying MBS item numbers—may trigger review.
How Do They Decide Who to Review?
The process usually begins with data analytics conducted by the Department of Health, looking for statistical outliers—doctors who bill far more than their peers for certain item numbers, or with unusual patterns of service provision.
Once flagged, the matter is referred to the Director of the PSR, who can decide whether to initiate a formal review. Peer comparison plays a major role: if your billing habits differ substantially from what’s considered normal for your specialty, you may be asked to explain why.
What Happens If My Billing Is Reviewed?
If the PSR initiates a review, you’ll typically be invited to respond in writing and may be asked to attend an interview. You might also be asked to provide medical records for sampled services. If concerns remain after this process, a formal committee of your peers may be convened to review your practice in detail.
Throughout the process, the focus is on whether your conduct aligns with what your professional peers would regard as appropriate.
What Are the Possible Outcomes?
There are several possible outcomes from a PSR review:
- Section 92 Agreement: This is a negotiated resolution between the practitioner and the Director of the PSR. It may involve repayment of benefits, partial disqualification from billing certain item numbers, or educational requirements.
- Review Committee Final Determination: If no agreement is reached, a formal committee may determine findings of inappropriate practice, potentially resulting in harsher penalties.
- Referral to the Chief Executive Medicare: This can lead to repayment orders, disqualification from Medicare or PBS, or both.
- Referral to AHPRA: In serious cases, professional conduct concerns may be escalated to the national regulator.
Sanctions can include:
- A reprimand
- Counselling
- Repayment of benefits for inappropriately claimed services
- Partial or full disqualification from Medicare or CDBS for up to 3 years
- Full disqualification from the PBS for up to 3 years
Common Pitfalls Leading to PSR Action
We looked back on the last five years of the PSR’s reports to establish how anaesthetists and ICU specialists may come to the attention of the PSR. Fortunately, only one anaesthetist and no ICU specialists had enforceable PSR action taken against them.
More broadly, there are consistent patterns in the behaviour deemed inappropriate:
- MBS requirements not being met: e.g., using item numbers without satisfying the time or complexity criteria.
- Lack of clinical justification: billing for services not clearly indicated or necessary.
- Inadequate clinical input: failing to examine or assess the patient properly.
- Poor documentation: sparse or non-existent medical notes.
- Billing for services not personally delivered, including billing for services when the patient was not even present (for real!).
Why This Matters for Anaesthetists and Intensivists
As anaesthetists and ICU specialists, we practise in high-pressure, complex clinical environments. But the intensity of our work does not exempt you from the obligation to document care appropriately and bill in accordance with Medicare rules. In fact, the Professional Services Review (PSR) has made it clear: even highly skilled practitioners can fall afoul of compliance rules if billing is not justified or supported by adequate records.
Services such as pre-operative assessments, after-hours claims, and consultation item numbers must be underpinned by both a clear clinical rationale and strict adherence to item number descriptors.
To reduce your risk of PSR scrutiny, make sure that for every item number you claim, you can demonstrate both:
- The service was clinically justified; and
- You have met all the specific requirements outlined in the item number descriptor and associated explanatory notes.
For Anaesthetists
Consultation item numbers are one of the most common sources of PSR investigation. For example, claiming a long consultation item (such as 17625) the day before surgery and then a short consultation (17610) immediately prior to the procedure can appear problematic. Unless there is a significant and documented clinical change, the second consult may not meet the threshold of being medically necessary—and may not be payable under Medicare.
For ICU Specialists
When using consultation item numbers (like 104 or 105), ensure there is a valid referral and that your input is specifically sought for management advice within your scope of expertise.
Reviewing a patient after ICU discharge—for example, after they’ve returned to the ward—can only be billed if there is a clinical issue that has been specifically referred to you by the treating specialist. Casual follow-up visits to “see how the patient is going” will not meet the Medicare standard for a payable consult and may trigger compliance concerns. Claiming “continuity of care” when the patient is not in intensive care is near-impossible to justify.
Stay Smart, Stay Safe
At Solo, we help anaesthetists and intensivists navigate the complexity of billing so they can focus on delivering excellent care. If you ever have questions about item numbers, appropriate billing practices, or how to tighten your documentation, our team is here to help.
If you’d like to explore recent PSR case outcomes, visit the PSR’s Case outcomes website.