{"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":"This instrument operationalises parts of the Health Insurance Act for the Professional Services Review (PSR) scheme: it defines which services are covered, prescribes exact patient‑record standards, sets numeric daily thresholds for review (including phone services), establishes witness allowances for PSR hearings, and names bodies to which serious matters may be referred. It primarily affects medical practitioners and practices by raising documentation and monitoring obligations and creating objective triggers that can prompt regulatory review."},"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"}}