{"id":"F2019L00180","name":"Health Insurance (Professional Services Review Scheme) Regulations 2019","slug":"health-insurance-professional-services-review-scheme-regulations-2019","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":98818,"registerId":"commonwealth-F2019L00180-current","compilationNumber":null,"startDate":"2026-04-02","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1—Preliminary","sortOrder":0},{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n This instrument is the Health Insurance (Professional Services Review Scheme) Regulations 2019.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This instrument is made under the Health Insurance Act 1973.","sortOrder":2},{"sectionNumber":"5","sectionType":"section","heading":"Definitions","content":"#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) general medical services table;\n (b) general practitioner;\n (c) Human Services Department;\n (d) medical practitioner;\n (e) professional service.\n In this instrument:\n\n> Act means the Health Insurance Act 1973.\n\n> practitioner has the same meaning as in Part VAA of the Act.\n\n> relevant phone service means a service specified in any of the following items of the general medical services table:\n\n (a) an item in any of the following Subgroups of Group A40:\n (i) Subgroup 2;\n (ii) Subgroup 8;\n (iii) Subgroup 10;\n (iv) Subgroup 16;\n (v) Subgroup 20;\n (vi) Subgroup 28;\n (vii) Subgroup 40;\n (viii) Subgroup 41;\n (b) an item in Subgroup 3 of Group A45;\n (c) an item listed in the following table.\n\n```html\n

Relevant phone services—individual items

Item

Column 1

Group or Subgroup

Column 2

Items of the general medical services table

1

Subgroup 26 of Group A40

92176, 92177

2

Subgroup 1 of Group A41

93302, 93305

3

Subgroup 2 of Group A41

93308, 93311

4

Subgroup 2 of Group A42

93423

5

Subgroup 4 of Group A42

93453

\n```\n\n> Note: Some services are specified in items set out in determinations under subsection 3C(1) of the Act.\n\n> relevant service means a service specified in any of the following items of the general medical services table:\n\n (a) an item in Group A1, A2, A5, A6, A7, A9, A11, A13, A14, A15, A17, A18, A19, A20, A21, A22, A23, A27, A35, A39, A41, A42, A43 or A45;\n (b) an item in Subgroup 1 or 4 of Group A36;\n (c) an item in any of the following Subgroups of Group A40:\n (i) Subgroup 1;\n (ii) Subgroup 2;\n (iii) Subgroup 3;\n (iv) Subgroup 10;\n (v) Subgroup 11;\n (vi) Subgroup 13;\n (vii) Subgroup 15;\n (viii) Subgroup 16;\n (ix) Subgroup 19;\n (x) Subgroup 20;\n (xi) Subgroup 21;\n (xii) Subgroup 27;\n (xiii) Subgroup 28;\n (xiv) Subgroup 29;\n (xv) Subgroup 39;\n (xvi) Subgroup 40;\n (xvii) Subgroup 41;\n (d) an item listed in the following table.\n\n```html\n

Relevant services—individual items

Item

Column 1

Group or Subgroup

Column 2

Items of the general medical services table

1

A29

139

2

A36

90264, 90265

3

Subgroup 17 of Group A40

92142

4

Subgroup 25 of Group A40

92170, 92171

5

Subgroup 26 of Group A40

92176, 92177

\n```\n\n> Note: Some services are specified in items set out in determinations under subsection 3C(1) of the Act.\n\n> service has the same meaning as in Part VAA of the Act.","sortOrder":3},{"sectionNumber":"Part 2","sectionType":"part","heading":"Prescribed matters for definitions","content":"## Part 2—Prescribed matters for definitions","sortOrder":4},{"sectionNumber":"6","sectionType":"section","heading":"Standards for adequate and contemporaneous records","content":"#### 6 Standards for adequate and contemporaneous records\n\n For the purposes of the definition of adequate and contemporaneous records in subsection 81(1) of the Act, the standards for a record of the rendering or initiation of services to a patient by a practitioner are that:\n (a) the record must include the name of the patient; and\n (b) the record must contain a separate entry for each attendance by the patient for a service; and\n (c) each separate entry for a service must:\n (i) include the date on which the service was rendered or initiated; and\n (ii) provide sufficient clinical information to explain the service; and\n (iii) be completed at the time, or as soon as practicable after, the service was rendered or initiated; and\n (d) the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Exceptional circumstances in relation to inappropriate practice","content":"#### 7 Exceptional circumstances in relation to inappropriate practice\n\n For the purposes of subsection 82(1D) of the Act, each of the following circumstances are exceptional circumstances for a particular day for a practitioner:\n (a) an unusual occurrence causing an unusual level of need for relevant services on the day;\n (b) an absence, on the day, of other medical services for the practitioner’s patients, having regard to:\n (i) the location of the practitioner’s practice; and\n (ii) the characteristics of the practitioner’s patients.","sortOrder":6},{"sectionNumber":"8","sectionType":"section","heading":"Circumstances for medical practitioners for prescribed pattern of services","content":"#### 8 Circumstances for medical practitioners for prescribed pattern of services\n\n For the purposes of section 82A of the Act, circumstances in which services rendered or initiated by a medical practitioner constitute a prescribed pattern of services are that:\n (a) the medical practitioner renders or initiates 80 or more relevant services on each of 20 or more days in a 12 month period; or\n (b) the medical practitioner renders or initiates 30 or more relevant phone services on each of 20 or more days in a 12 month period.","sortOrder":7},{"sectionNumber":"Part 3","sectionType":"part","heading":"Professional Services Review Committees","content":"## Part 3—Professional Services Review Committees","sortOrder":8},{"sectionNumber":"9","sectionType":"section","heading":"Allowances for witnesses at hearings","content":"#### 9 Allowances for witnesses at hearings\n\n (1) This section is made for the purposes of subsection 106C(1) of the Act and deals with allowances for expenses in respect of attendance by a person summoned to appear as a witness at a hearing before a Professional Services Review Committee.\n Kinds of allowances\n (2) The allowances for a witness are the following:\n (a) attendance allowance in accordance with subsection (3) or (4) as applicable;\n (b) travel allowance in accordance with subsection (5).\n Amount of attendance allowance\n (3) For a witness attending because of the witness’ professional, scientific or other special skill or knowledge, the amount of attendance allowance is equal to the witness’ actual fees for preparing to give evidence and of attending to give evidence.\n (4) For a witness other than a witness mentioned in subsection (3), the amount of attendance allowance is equal to:\n (a) if the witness is paid by salary—any salary actually lost because of the attendance; or\n (b) if the witness is paid by wages—any wages actually lost because of the attendance; or\n (c) if the witness is paid by fees—any fees actually lost because of the attendance;\n up to a maximum of $527 per day.\n Amount of travel allowance\n (5) The amount of travel allowance for a witness is a reasonable amount, determined in relation to the witness by the Professional Services Review Committee, for:\n (a) transport to and from the hearing; and\n (b) if the witness is required to be absent overnight from the witness’ usual place of residence—meals and accommodation during the absence.","sortOrder":9},{"sectionNumber":"Part 4","sectionType":"part","heading":"Referral of professional issues to regulatory and other bodies","content":"## Part 4—Referral of professional issues to regulatory and other bodies","sortOrder":10},{"sectionNumber":"10","sectionType":"section","heading":"Specified persons and bodies—significant threat to life or health","content":"#### 10 Specified persons and bodies—significant threat to life or health\n\n (1) For the purposes of paragraph 106XA(4)(a) of the Act, this section specifies persons and bodies for persons who render professional services.\n General practitioners\n (2) The following persons and bodies are specified for a person who renders professional services who is a general practitioner:\n (a) the Australian College of Rural and Remote Medicine;\n (b) Australian General Practice Accreditation Limited;\n (c) the Australian Health Practitioner Regulation Agency;\n (d) the Health Care Complaints Commission of New South Wales;\n (e) the Health Ombudsman of Queensland;\n (f) the Medical Board of Australia;\n (g) the Medical Council of New South Wales;\n (h) Quality Practice Accreditation Pty Ltd;\n (i) the Royal Australian College of General Practitioners.\n Persons who are not general practitioners\n (3) The following persons and bodies are specified for a person who renders professional services who is not a general practitioner:\n (a) the Aboriginal and Torres Strait Islander Health Practice Board of Australia;\n (b) the Australian Health Practitioner Regulation Agency;\n (c) the Chinese Medicine Board of Australia;\n (d) the Chiropractic Board of Australia;\n (e) the Dental Board of Australia;\n (f) the Department;\n (g) the Health Ombudsman of Queensland;\n (h) the Human Services Department;\n (i) the Medical Board of Australia;\n (j) the Medical Council of New South Wales;\n (k) the Medical Radiation Practice Board of Australia;\n (l) the Nursing and Midwifery Board of Australia;\n (m) the Optometry Board of Australia;\n (n) the Osteopathy Board of Australia;\n (o) the Paramedicine Board of Australia;\n (p) the Pharmacy Board of Australia;\n (q) the Physiotherapy Board of Australia;\n (r) the Podiatry Board of Australia;\n (s) the Psychology Board of Australia.","sortOrder":11},{"sectionNumber":"11","sectionType":"section","heading":"Specified bodies—non‑compliance with professional standards","content":"#### 11 Specified bodies—non‑compliance with professional standards\n\n General practitioners\n (1) For the purposes of subsection 106XB(3) of the Act, a body is specified in relation to a practitioner who is a general practitioner if:\n (a) the body:\n (i) is specified in subsection 10(2) of this instrument; and\n (ii) has the power to take action against the practitioner if the practitioner has failed to comply with professional standards; or\n (b) the body has the function of assisting a person who:\n (i) is specified in subsection 10(2) of this instrument; and\n (ii) has the power to take action against the practitioner if the practitioner has failed to comply with professional standards.\n Practitioners who are not general practitioners\n (2) For the purposes of subsection 106XB(3) of the Act, a body is specified in relation to a practitioner who is not a general practitioner if:\n (a) the body:\n (i) is specified in subsection 10(3) of this instrument; and\n (ii) has the power to take action against the practitioner if the practitioner has failed to comply with professional standards; or\n (b) the body has the function of assisting a person who:\n (i) is specified in subsection 10(3) of this instrument; and\n (ii) has the power to take action against the practitioner if the practitioner has failed to comply with professional standards.","sortOrder":12},{"sectionNumber":"Part 5","sectionType":"part","heading":"Transitional provisions","content":"## Part 5—Transitional provisions","sortOrder":13},{"sectionNumber":"12","sectionType":"section","heading":"Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (2022 Measures No. 4) Regulations 2022","content":"#### 12 Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (2022 Measures No. 4) Regulations 2022\n\n Paragraph 8(b) applies in relation to relevant phone services rendered on or after 1 October 2022.","sortOrder":14}],"analysis":{"flash_summary":{"complexity_score":5,"scope_assessment":{"changed":true,"description":"The instrument includes a transitional provision that makes paragraph 8(b) (the 30-or-more relevant phone services threshold) apply to relevant phone services rendered on or after 1 October 2022, thereby setting the effective date for that element of the prescribed-pattern rule. (See: section 12.)"},"complexity_factors":["Extensive cross-references to the Health Insurance Act 1973 (the Act) and to determinations under subsection 3C(1) of the Act (see sections 3 and notes in section 5)","Detailed, itemised lists of services and phone services by group/subgroup and individual item numbers (section 5 tables)","Quantitative thresholds that require counting services across days and a 12‑month period (section 8)","Prescriptive record-keeping requirements with timing and content elements (section 6)","Delegated discretion for allowances (committee determines travel allowances; capped amounts and actual-loss approaches for attendance allowance) (section 9)","Multiple specified referral bodies with different roles and powers (sections 10–11)","A transitional provision changing the effective date for one threshold (section 12)"],"plain_english_summary":"What this instrument does\n\n- This instrument, made under the Health Insurance Act 1973, sets out detailed definitions, standards and procedural rules that apply to the Professional Services Review (PSR) scheme. (See: section 3 and the headings throughout.)\n\nKey mechanical changes and rules\n\n- Definitions: It identifies and defines a number of technical terms used in the PSR context, in particular detailed lists of \"relevant services\" and \"relevant phone services\" by reference to groups, subgroups and individual item numbers in the general medical services table. The instrument also notes that some services may be specified by separate determinations under subsection 3C(1) of the Act. (See: section 5 and the two item tables described there.)\n\n- Record standards: For the purpose of the Act's definition of \"adequate and contemporaneous records\", the regulations prescribe exactly what a patient record must contain: patient name; a separate entry for each attendance; each entry must show the date, provide sufficient clinical information to explain the service, and be completed at the time or as soon as practicable after the service; and the record must be sufficiently comprehensible to allow another practitioner to continue care. These standards are expressly made \"for the purposes of the definition\" in subsection 81(1) of the Act. (See: section 6.)\n\n- Exceptional circumstances: The regulations say what counts as \"exceptional circumstances\" (for the purposes of subsection 82(1D) of the Act) for a particular day: an unusual occurrence creating an unusual level of need for relevant services that day, or the absence on that day of other medical services for the practitioner’s patients, having regard to practice location and patient characteristics. (See: section 7.)\n\n- Prescribed pattern thresholds: The instrument prescribes quantitative thresholds (for section 82A of the Act) that define a \"prescribed pattern of services\" by a medical practitioner. A prescribed pattern arises if, in a 12-month period, the practitioner: either (a) renders or initiates 80 or more relevant services on each of 20 or more days; or (b) renders or initiates 30 or more relevant phone services on each of 20 or more days. (See: section 8.)\n\n- Witness allowances at PSR Committee hearings: The regulations specify the kinds of allowances available to a person summoned as a witness before a PSR Committee (attendance allowance and travel allowance), how attendance allowance is calculated (actual professional fees for expert witnesses; actual salary/wages/fees lost for other witnesses, up to a daily cap of $527), and that travel allowance is a reasonable amount determined by the Professional Services Review Committee for transport and, if an overnight stay is required, meals and accommodation. (See: section 9.)\n\n- Referral channels: The instrument lists the specific organisations and regulatory bodies to which professional issues may be referred when a person’s conduct presents a \"significant threat to life or health\" (different lists for general practitioners and for other practitioners). It also specifies which bodies are to be treated as having a power to take action (or to assist a body that does) in relation to non‑compliance with professional standards. These lists identify a set of professional boards, accreditation bodies, state complaint agencies, the Department and the Human Services Department, among others. (See: sections 10 and 11.)\n\n- Transitional provision: One specified amendment (paragraph 8(b), the 30-per-day phone-service threshold) is stated to apply only to relevant phone services rendered on or after 1 October 2022. (See: section 12.)\n\nStated purposes and how those purposes interact with costs, incentives and implementation\n\n- Purpose-claims: The instrument repeatedly frames particular rules as being \"for the purposes of\" specified provisions of the Act (for example, sections 6, 7, 8 and 9 explicitly state they are made for the purposes of specific subsections of the Act). That is, the regulations are presented as the specific, operational specifications the Act requires. (See: sections 6–9.)\n\n- Compliance burden and costs: The record-keeping standard (section 6) imposes clearly articulated documentation requirements: separate entries, dates, clinically sufficient information, and timely completion. Those requirements create an administrative burden on practitioners to keep contemporaneous and comprehensible records. The quantified thresholds in section 8 create a monitoring burden (practitioners or their practices must be able to count and, if necessary, explain service-day counts). Both types of requirements imply time and administrative cost to practitioners and practices.\n\n- Incentives and behaviour: The thresholds in section 8 define objective triggers that may prompt review under the PSR scheme. That creates an incentive for practitioners and practices to monitor daily service volumes and phone-service volumes, and may shape how services are recorded or scheduled. The exceptional-circumstances rule in section 7 provides a stated route to account for one-off spikes in activity, which mitigates rigid application of the numeric thresholds for days affected by unusual events.\n\n- Bureaucratic discretion and implementation risk: The Professional Services Review Committee has explicit discretion in determining travel allowances and in applying the allowances framework (section 9(5)). Referral decisions follow the lists in sections 10 and 11, but whether and how a specified body takes action depends on that body's statutory powers. The instrument also defers to determinations made under subsection 3C(1) of the Act for specifying additional services, so the list of covered items can be changed through instruments external to these regulations (see notes in section 5). Those features mean administrative practice and external determinations can materially affect how the rules operate in practice.\n\n- Effects on private choice and markets: The instrument regulates professional behaviour and professional oversight rather than markets directly. By specifying record standards and review triggers, it affects how practitioners document and deliver services (including phone-based services listed in section 5 and thresholded in section 8). The specified referral bodies (sections 10–11) channel reviews toward professional and regulatory responses rather than, for example, immediate financial penalties set out here.\n\nWho pays, who decides, and what changes in behaviour\n\n- Who decides: The Professional Services Review Committee applies the allowances rules (section 9), and the list of bodies in sections 10 and 11 determine referral options for significant threats to life/health and for non‑compliance with professional standards. Other listed organisations \"have the power to take action\" or \"have the function of assisting\" such bodies (section 11). Determinations under subsection 3C(1) of the Act (outside this instrument) can add to the lists of services covered (section 5 notes).\n\n- Who pays: The regulations set the amounts that may be provided as allowances for witnesses in PSR Committee hearings (section 9) and cap non-expert witness attendance loss at $527 per day (section 9(4)). The instrument itself does not set out the payor by name; it prescribes the amounts and gives the Committee discretion to determine reasonable travel allowances (section 9(5)).\n\n- Behaviour changes required: Practitioners must maintain records meeting the specified standards (section 6); practices should monitor service volumes against the thresholds in section 8 to understand whether activity patterns might be treated as a \"prescribed pattern\"; and practitioners should be aware of the specific referral bodies listed in sections 10 and 11 that their matters may be forwarded to.\n\nAreas of trade‑offs and potential unintended effects to watch for\n\n- Concentrated monitoring cost: The counting rules and documentation standards are precise, so small practices may bear a relatively larger administrative cost to comply than larger practices with existing administrative systems (see sections 6 and 8).\n\n- Substitution and recording effects: Because thresholds are numeric and tied to service counts and phone-service counts (section 8), there is a potential for behaviour or recording changes aimed at avoiding threshold triggers (for example, altering how, when or whether services are billed or recorded). The exceptional-circumstances provision (section 7) addresses some day‑level spikes but does not remove the need to monitor monthly and annual patterns.\n\n- Dependence on external instruments and bodies: The lists of services rely in part on the general medical services table and on determinations under subsection 3C(1) of the Act (section 5 notes). Referral and sanctioning depend on the statutory powers and practices of the bodies named in sections 10 and 11. That means the practical effect of these regulations can shift as those external instruments or bodies change practice.\n\nBottom line\n\n- The instrument operationalises parts of the Health Insurance Act by prescribing: detailed service definitions, clear record-keeping standards, numeric thresholds that can trigger review, a framework for witness allowances at PSR hearings, specific referral targets for serious matters, and an effective date for the phone‑service threshold. Those prescriptions change the compliance tasks and monitoring incentives for practitioners and give decision-making roles to PSR Committees and the named referral bodies. (See: sections 5–12.)"},"kimi_summary":{"content_quality":"ok","complexity_score":5,"scope_assessment":{"changed":false,"description":"The legislation appears to maintain its original scope as regulations supporting the Professional Services Review Scheme under the Health Insurance Act 1973. The 2022 amendment adding phone service thresholds (section 12) represents an expansion to cover telehealth, but this is a logical evolution of the scheme rather than scope creep — it updates the mechanism to reflect modern practice patterns without fundamentally altering the purpose of detecting inappropriate Medicare billing."},"complexity_factors":["Extensive cross-referencing to the Health Insurance Act 1973 and the Medicare Benefits Schedule (general medical services table)","Two detailed tables listing specific Medicare item numbers by Group and Subgroup (A40, A41, A42, A45 etc.)","Multiple defined terms that rely on definitions in the parent Act (practitioner, service, etc.)","Conditional logic for exceptional circumstances requiring assessment of 'unusual occurrence' and geographic factors","Differential treatment of general practitioners versus non-GP practitioners in Part 4 (separate lists of regulatory bodies)","Nested definitions: 'relevant service' and 'relevant phone service' are defined by reference to items in the general medical services table, which itself is defined in the Act","Transitional provision with specific date trigger (1 October 2022) for phone service amendments"],"plain_english_summary":"This legislation sets out the rules for reviewing how doctors and other health professionals bill Medicare (Australia's public health insurance system). It aims to catch inappropriate billing practices while protecting patients and ensuring fair process.\n\n**What it does:**\n\n* **Defines which services are monitored:** It lists specific Medicare item numbers that are considered \"relevant services\" and \"relevant phone services\" — these are the types of medical consultations and telehealth calls that get scrutinised for potential over-billing or inappropriate practice.\n\n* **Sets billing thresholds:** A doctor triggers a \"prescribed pattern of services\" (a red flag for review) if they bill 80 or more relevant services on each of 20 or more days in a year, OR 30 or more phone consultations on each of 20 or more days in a year.\n\n* **Sets record-keeping standards:** Doctors must keep proper patient records — including patient name, date of service, and enough clinical detail that another doctor could continue the patient's care. Records must be made at the time or soon after the service.\n\n* **Allows exceptions:** \"Exceptional circumstances\" (like a local emergency or being the only doctor available in a remote area) can excuse high billing numbers.\n\n* **Pays witnesses:** It sets out how much witnesses get paid when they appear before a Professional Services Review Committee (the body that investigates doctors), including lost wages or professional fees up to $527/day plus travel costs.\n\n* **Names who gets told about problems:** It lists which medical boards and regulatory bodies must be notified if a doctor poses a \"significant threat to life or health\" or has failed to meet professional standards. Different lists apply for GPs versus other specialists.\n\n**Who it affects:**\n\n* Doctors and other health professionals who bill Medicare\n* Patients (indirectly — protects them from unnecessary services)\n* Medicare and the Professional Services Review Committees\n* Medical regulatory bodies (like AHPRA and the Medical Board)\n\n**Why it matters:**\n\nThis is the operational rulebook for catching Medicare fraud and over-servicing. It balances cracking down on dodgy billing with protecting doctors who work in difficult circumstances or have legitimate reasons for high patient numbers. The phone consultation rules were updated in 2022 to reflect the boom in telehealth services."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019","history":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019/history","analysis":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019/analysis","conflicts":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019/conflicts","importantCases":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019/important-cases","documents":"/api/acts/health-insurance-professional-services-review-scheme-regulations-2019/documents"}}