In our last article, we looked at Stage 1 of the PSR process. In this article we will do the same for Stage 2.
Often by this stage, having gone through Stage 1, the person under review is already feeling the mental stress and exhaustion that comes with this process, so let me reiterate the importance of self-care and pacing in between and throughout these processes.
What happens in Stage 2?
This is probably one of the most difficult things I have experienced in my life as a medical practitioner – above and beyond life-and-death resuscitations that we have all experienced somewhere in our journey.
After the Director makes a decision that further investigation is needed or the practitioner decides that he or she will not enter a negotiated agreement, a committee of your peers is formed and appointed by the Director from the Panel of Doctors appointed by the health minister. The panel is appointed by the minister with discussion and guidance from relevant colleges and the AMA. Often the panel doctors are college executives and/or members of the AMA.
The Director will give you the opportunity to voice any concern for bias. This will need to be legally argued, and ultimately the Director can decide to remove a panel member and replace them with someone else, if bias is present. After this the dates are set for the committee hearing. This usually spans between two and six days. Some have had these hearings conducted in a magistrate’s court setting, but more recently they have been conducted in office buildings set up for an interrogation and interview process.
Before the committee hearing the person under review will have the chance to review item numbers and the sample of medical records being used for each item number, and can provide oral submissions to the committee about the patient records, their own practice pattern and reasoning behind their billing pattern.
The committee will set their own peer standards and judge whether you have inappropriately billed or not. During the interrogation, you are allowed to call people to give evidence about the item numbers, and your conduct. The committee will allow you to put in any written evidence, additional notes, references, support letters, expert reports etc during the review.
You are allowed to also have support people with you during the hearing and this can include your lawyer; however, all oral evidence is given by yourself directly.
You can ask your lawyer to give a final summary submission at the end of the interrogation, but they cannot cross-examine or question the committee or speak on your behalf during the committee hearing.
After the final hearing is concluded, the committee will take a few months to consider and provide you with a report of their preliminary findings. You have the right to make submissions in response to these findings and finally, after the committee considers your final submissions, they will issue a final report with their conclusions, which will be sent to you and the Determining Authority (Stage 3) to ratify.
What does it practically feel and look like going through this process?
The days of interrogations are exhausting, long and probably one of the most challenging things one will go through as a health professional.
The days are usually eight hours and it is a constant information overload game, where at times you feel like curling up in a fetal position and vanishing. It is a challenge to your own ego and pride as a professional.
The Standards applied by the committee tend to be extremely high and at times one may say unrealistic in everyday practice.
I still remember saying to the committee I wish I had the opportunity to go through this process as medical student so that we could have been taught the golden standards now being applied by the committee. If this was not such a financially and professionally detrimental process – if it were not so devastating – it could be seen as a great learning opportunity.
Pearls for surviving Stage 2:
- Gather your hive. You need to not only have an expert legal team, but you really need the help of your peers external to the PSR process who can support you both professionally and personally.
- Getting peer reviews in favour of your practice may help your situation greatly.
- Always take a support person and your legal counsel to these sessions.
- Make sure you take breaks, eat, sleep the night before and face these days as composed and articulate as possible.
- Do not become emotional, angry or rude.
- Get a copy of your transcript for further reference.
- Make sure you have reviewed every single case note prior to your investigation date so that you can answer any questions.
- Have a little opening spiel ready i.e. “My recollection of this particular case is that this is a case of a 38 yo F etc. with these problems, and my approach to her/his care was xyz and my impression of her/his situation was this.” Or be frank and say, “I do not have a recollection of this patient, however upon review of my medical records, it is my submission and understanding that this patient was etc.”
- Approach this as you would a clinical-based discussion where you are talking about your approach of practice and illustrating that you have in fact put sufficient clinical input to this patient to have billed e.g. a long consultation or a care plan.
Again, always as final note, this is not a sprint, it is a marathon so look after yourself, pace yourself and make sure you are at your best when you go into these stages.
Dr Anchita Karmakar is the founder and CEO of AHPAS (Australian Health Professionals Advisory Service) and a medicolegal liaison officer at Work Legal