{"id":"F2017L00274","name":"Health Insurance (Professional Services Review – Sampling Methodology) Determination 2017","slug":"health-insurance-professional-services-review-sampling-methodology-determination-2017","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":439142,"registerId":"F2017L00274-fast-fetch-1775955265082","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Health Insurance (Professional Services Review – Sampling Methodology) Determination 2017","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n![](image.001.png)\n\nHealth Insurance (Professional Services Review — Sampling Methodology) Determination 2017\n\nHealth Insurance Act 1973\n\nI, GREG HUNT, Minister for Health, make this Determination under subsection 106K (3) of the Health Insurance Act 1973.\n\nDated    15 March 2017\n\nGREG HUNT\n\nMinister for Health\n\nContents\n\n[Part 1 Preliminary](#_Toc476743819)\n\n[1 Name of Determination](#_Toc476743820)\n\n[2 Commencement](#_Toc476743821)\n\n[3 Authority](#_Toc476743822)\n\n[4 Schedules](#_Toc476743823)\n\n[5 Definitions](#_Toc476743824)\n\n[Part 2 Sampling methodology](#_Toc476743825)\n\n[6 Purpose](#_Toc476743826)\n\n[7 Application of sampling methodology](#_Toc476743827)\n\n[8 Sample](#_Toc476743828)\n\n[9 Determining percentage of inappropriate practice in sample](#_Toc476743829)\n\n[10 Disregarding sample results less than 10%](#_Toc476743830)\n\n[Part 3 Transitional](#_Toc476743831)\n\n[11 Definitions](#_Toc476743832)\n\n[12 Continued operation of the previous determination to certain investigations](#_Toc476743833)\n\n[Schedule 1—Repeals](#_Toc476743834)\n\n[1 The whole of the Determination](#_Toc476743835)\n\n \n\n# Part 1 Preliminary\n\n \n\n### 1 Name of Determination\n\n  This Determination is the Health Insurance (Professional Services Review – Sampling Methodology) Determination 2017.\n\n### 2 Commencement\n\n  This Determination commences on the day after it is registered.\n\n### 3 Authority\n\n  This Determination is made under section 106K of the Health Insurance Act 1973.\n\n### 4 Schedules\n\n  Each instrument that is specified in a Schedule to this Determination is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.\n\n### 5 Definitions\n\n  In this Determination:\n\nAct means the Health Insurance Act 1973.\n\nfinal report means:\n\n1.    a final report prepared under section 106L of the Act; or\n2.    a draft report prepared under section 106KD of the Act that is, because of the operation of section 106KE of the Act, also a final report.\n\n\nNote 1   The following terms that are used in this Determination are defined in subsection 3 (1) of the Act:\n\n initiate\n\n item.\n\nNote 2   The following terms that are used in this Determination are defined in subsection 81 (1) of the Act:\n\n class of services\n\n Committee\n\n inappropriate practice\n\n person under review\n\n referred services\n\n service.\n\n\n\n\n# Part 2 Sampling methodology\n\n \n\n### 6 Purpose\n\n  This Part specifies the content and form of a sampling methodology that may be used by a Committee in investigating the provision of services included in a particular class of referred services, where regard is to be had only to a sample of the services included in the class.\n\n### 7 Application of sampling methodology\n\n  The sampling methodology specified in this Part is applicable to services provided, within the meaning given by subsection 81 (2) of the Act, that are:\n\n (a) individual items; or\n\n (b) multiple items for the same patient on 1 occasion;\n\nin a particular class of referred services.\n\n### 8 Sample\n\n (1) Under this methodology, the Committee must have regard to a sample of no fewer than 25 provided services randomly drawn from a class of referred services being investigated.\n\n (2) The Committee may:\n\n (a) omit a service from the sample; and\n\n (b) include another provided service, randomly drawn from the same class, in its place.\n\n (3) If the Committee omits a service and includes another provided service in its place under subsection (2), the Committee must state its reasons for doing so in the draft report and final report it prepares in respect of the person under review to whom the sample relates.\n\nNote   The Committee must prepare a draft report under section 106KD of the Act, and a final report under section 106L of the Act, in relation to its findings. The draft report may also constitute a final report, where all or a majority of the Committee do not find the person under review engaged in inappropriate practice (see section 106KE of the Act).\n\n### 9 Determining percentage of inappropriate practice in sample\n\n (1) A Committee relying on subsection 106K (1) of the Act must work out, in accordance with subsection (2), the proportion of services in the sample in relation to the provision of which the person under review engaged in inappropriate practice.\n\n (2) For subsection (1), the proportion is to be expressed as a percentage, as follows:\n\n![](image.002.png)\n\nwhere:\n\nd is the number of services in the sample that the Committee has determined are services in relation to the provision of which the person under review engaged in inappropriate practice, divided by s.\n\ns is the number of services in the sample.\n\nN is the number of services in the class.\n\n (3) If the percentage worked out under subsection (2) is not a whole percentage, it is to be rounded down to the nearest whole percentage.\n\n### 10 Disregarding sample results less than 10%\n\n  For the purpose of subsection 106K (1) of the Act, the methodology specified in this Determination may be used by a Committee only if the percentage worked out under section 9 is equal to, or greater than, 10% of the sample of the particular class of referred services under investigation.\n\nNote 1   It is considered that no conclusion can be drawn from a result less than 10%, because the result may not be statistically valid.\n\nNote 2   Information about a service may be considered under section 106H of the Act even if, because of this section, a sample including that service cannot be considered under section 106K of the Act.\n\n\n\n\n# Part 3 Transitional\n\n### 11 Definitions\n\n \n\nIn this Part:\n\ncommencement time means the commencement of this Determination.\n\nprevious determination means Health Insurance (Professional Services Review — Sampling Methodology) Determination 2006 as in force immediately before the commencement time.\n\n### 12 Continued operation of the previous determination to certain investigations\n\n(1) This section applies if:\n\n(a) before the commencement time a referral has been made to a Committee under section 93 of the Act to investigate the provision of services by a person under review; and\n\n(b) a final report has not been made in relation to the investigation at the commencement time.\n\n(2) Despite the repeal of the previous determination, it continues to apply to the investigation of the provision of services after the commencement time as if the repeal had not happened.\n\n# Schedule 1—Repeals\n\nHealth Insurance (Professional Services Review – Sampling Methodology) Determination 2006\n\n### 1 The whole of the Determination\n\nRepeal the Determination.\n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":3,"scope_assessment":{"changed":false,"description":"The legislation maintains its original narrow purpose: prescribing a specific statistical sampling methodology for Professional Services Review Committees. The 2017 version replaces the 2006 version with essentially the same scope—updated procedural rules for the same investigatory function. No scope creep detected."},"complexity_factors":["Short document (only 12 substantive sections plus a repeal schedule)","Minimal defined terms (only 3 defined in Part 1, plus references to existing Act definitions)","Single clear purpose with straightforward procedural rules","One mathematical formula with clearly defined variables (d, s, N)","Simple transitional provision (grandfathering existing investigations)","No nested exceptions or complex conditional logic beyond basic 'if-then' structures"],"plain_english_summary":"This Determination prescribes the statistical sampling method Professional Services Review Committees must use when investigating suspected improper Medicare billing. Committees must randomly review at least 25 services, may replace sampled items (with reasons), and calculate the defect rate; if fewer than 10% of sampled services are improper the sample can’t be used against the practitioner.  \n\nIt affects investigated clinicians, review committees, and the Department of Health by standardising fair, defensible audits."},"flash_summary":{"complexity_score":3,"scope_assessment":{"changed":true,"description":"This instrument replaces the 2006 Sampling Methodology and sets specific, narrower procedural rules for using samples in Professional Services Review investigations: a 25‑service minimum, a defined percentage formula with rounding, and a 10% floor below which sample results cannot be relied on (sections 8–10). It also narrows application to single items or multiple items for the same patient on one occasion (section 7) and preserves the prior rules only for investigations referred before commencement (section 12 and Schedule 1)."},"complexity_factors":["Mathematical sampling formula using variables N (class size), s (sample size) and d (number adverse) (section 9)","Rounding rule for percentages that rounds down to the nearest whole percentage (section 9(3))","Minimum sample size requirement of 25 services (section 8(1))","10% threshold that disqualifies sample-based conclusions under that level (section 10)","Authority to omit and replace sampled services but with an obligation to state reasons in draft and final reports (sections 8(2)–(3))","Limited application to individual items or multiple items for the same patient on one occasion (section 7)","Repeal of the 2006 Determination with a transitional saving for investigations already referred (section 12 and Schedule 1)"],"plain_english_summary":"This Determination tells the Professional Services Review Committee how to sample a practitioner’s Medicare services during an investigation. It requires a random sample of at least 25 services, allows replacing omitted services if reasons are recorded, prescribes a formula and rounding to convert sample findings into a percentage, and bars using sample-based conclusions under 10%. It affects practitioners under review and the Committee’s evidentiary process."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017","history":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017/history","analysis":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017/analysis","conflicts":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017/conflicts","importantCases":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017/important-cases","documents":"/api/acts/health-insurance-professional-services-review-sampling-methodology-determination-2017/documents"}}