15 March 2022

Naughty and NOCE: life after PSR

AHPRA Comment KnowCents Medicare PSR

It doesn’t all end with a great big bill – there are a few other sequelae to be prepared for.

Recently there seems to be a shift in the paradigm of what occurs after a practitioner goes through a Professional Services Review process or audit experience. 

We are increasingly seeing interesting after-effects, with many practitioners feeling a sense of anxiety and fear of the unknown – so I felt it might be helpful look at some of the real ramifications and issues one may face as a regulated doctor after the investigations are concluded. 

Here are three common pathways that we have seen taken by practitioners. 

1) “Certain Events” 

Once you go through the PSR/PRP process, whether you finish in stage 1 or in the final stage 3, under the National Law you are obliged – as if you haven’t been through enough – to make a self-notification to AHPRA about what has occurred. 

This is done with the form called “NOCE”, short for Notice of Certain Events. It’s kind of cute when you read it out loud and perhaps it’s the regulators way to try and make this less scary, but essentially it is exactly what it says. It is you as a health practitioner notifying the regulators about certain events that have taken place. 

Findings of inappropriate billing is a professional misconduct issue, and this information needs to be given to AHPRA for consideration. This notification must be made within seven days of the investigation concluding and it will usually need a letter of explanation to ensure AHPRA doesn’t get the wrong idea and start a parallel investigation. 

The letter by your solicitor should explain what has occurred, perhaps a copy of the determination, the item numbers of concern and any limitations you have got on your billing abilities. This usually will be received by AHPRA, then referred to the relevant regulatory authority of your state i.e. OHO/HCCC, and if they find no concerns they usually refer it back to AHPRA for them to conclude and thank you for your notification and compliance with the National Law. 

So what is the big deal? 

Well, fundamentally we all have a little chill and goosebump moment whenever we hear the regulators are getting involved. It is that “oh no … I may be prevented from making a living!” fear factor. I think perhaps this fear is a hard one to overcome as in Australia, as clinicians we are at the mercy of the regulators and must abide by their rules. 

The good news is that most of the time, with proper explanation and support, this becomes merely a formality that you do not need to worry about but must comply with so it does not become a big deal. 

The other issue that a lot of us experience is the annoying waiting period. Although it looks and smells and tastes like simply a formality, for some reason it takes a long time to be concluded in most cases. During these months you are kind of in a limbo waiting to see if this long journey will finally come to an end or if you need to prep up for another battle. 

My suggestion is to exercise what I call the a “therapeutic pause”. Understand that this will take time, let yourself forget and relax for a while being all you can really do is wait and have faith in the system and your solicitors to push for a favourable outcome. 

Don’t let yourself burn up with anxiety and fear while you wait, as it may affect not only your own health but further adverse professional outcomes. It becomes a vicious cycle – so snap out of it and chill. 

2) A life sentence?

Once you have been investigated and found guilty, this is a professional label that will be with you for life. It is something you have to swallow, no matter how sour, because the worst thing you can do is fail to disclose it when relevant. 

For example, I am a fully qualified legal graduate. In Queensland, to become a practising lawyer you must meet not only eligibility criteria but also suitability criteria. Although I have fulfilled the eligibility criteria, due to my previous history of audit my suitability is now under investigation and consideration of the Supreme Court and the Legal Board. 

I have had to disclose everything that has happened to me and wait and wait and wait and wait until all the information is available to apply for my admission as a lawyer – this is not a nice thing to go through, but it must be done and accepted. 

The PSR process is not something you just live through and “move on” from. It will affect the way you go forward forever, hence the importance of understanding its consequences and mentally preparing yourself. 

The key, I find, to all this is the concept of acceptance and learning. Once you have mastered these, the sky is your limit. The more candid you are about it, the more the negative ramifications dwindle. I feel this at every turn of my journey. 

The other tip I have that a lot of us smart doctors struggle with is not to take it all too personally. Being compliant with the laws and regulation of this highly regulated system can be challenging. If you have been caught up in the storm of investigations, see what you can learn from this, but understand that it does not define you as a clinician or a person. 

3) Money does not grow on trees

The final and for most people the scariest implication is the financial one, especially for those found to have overserviced. 

Generally, what happens is this. Once you get the bill from Medicare, if you cannot agree to a reasonable payment arrangement (usually Medicare would like you to repay the whole amount within two years), you will need to provide your financial details, including your partner’s financial details. This forces you to create a budget and a review of your finances to see what cash flow you have and how you can bring this debt down. 

Your accountant should also be talking to you about adjustment of tax, as technically you are being told you did not make this amount of money which should mean you will get some tax refund. 

It is always a fear that perhaps Medicare may come down harsh and nasty about it all. However, from my own experience and from what I hear, as long as you are reasonable, hardworking and candid about your situation, keeping an open channel of communication and showing genuine effort of repayment, usually things do not go pear shaped. 

It is also very important to ensure you keep communicating with your lawyers to explore options for trying to get some of the repayments back from your previous employer/practice etc. – because of course, most of us would not have taken home the entire sum of billings that we are being forced to give back. 

The fear is real and we will all have those intermittent sleepless nights – but all in all, at the end we should all be ok. It is not the end of the world. 

The other best part? You are certainly not alone. Nowadays as the regulators crank up their compliance activities, not being audited seems to be the rare characteristic, so do not feel isolated or shamed. Ask for help early on and make sure you are defending and explaining yourself properly from the beginning.  

Dr Anchita Karmakar is the founder and CEO of AHPAS (Australian Health Professionals Advisory Service); a medicolegal liaison officer at Work Legal; and an ACRRM rural generalist independent pathway registrar with a special interest in population health.