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Commonwealth legislation
This Act has been repealed and is no longer in force. It is retained for historical reference.
These Directions set the statistical procedure the Professional Services Review Committee must use when making findings from samples of claimed services under the Health Insurance Act 1973. They prescribe random selection, an initial 30-case exploratory sample with a 20% trigger, lookup tables for final sample sizes, a 10 percentage-point downward adjustment (95% confidence), and an option for the practitioner to double the sample. The rules affect practitioners under review, the Commission/Committee that examines cases, and administrative staff who must apply the tables and calculations.
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Direct links to the current provisions in Professional Services Review Scheme - Directions as to Sampling (No. 2).
Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.
Health Insurance Act 1973
Professional Services Review Scheme –
Directions as to Sampling (No. 2)
I, CARMEN MARY LAWRENCE, Minister for Human Services and Health, acting under section 106K of the Health Insurance Act 1973, issue the following Directions, being directions that are in accordance with advice received from the Australian Bureau of Statistics, for the purposes of sections 106H and 106J of that Act.
Dated 31 January 1995
CARMEN LAWRENCE
Minister for Human Services and Health
_____________
PART 1 – PRELIMARY
1.1 This Direction may be cited as Professional Services Review Scheme – Directions as to Sampling (No. 2).
1.2 This Direction sets out procedures in regard to samples of services for the purposes of Subdivision C (Findings based on statistical sampling) of Division 4 of Part VAA of the Health Insurance Act 1973 (the Act).
1.3 Terms used in this Direction that are defined in Part VAA of the Act have the same meanings in this Direction as in that Part.
1.4 Part 2 of this Direction sets out the procedure for producing and using a sample for the purposes of subsection 106H(1) of the Act. Part 3 sets out the procedure for increasing the size of a sample if the practitioner under review so requests under subsection 106J(2) of the Act.
Professional Services Review Scheme – Directions as to Sampling
1.5 A sample produced for any purpose referred to in these Directions must be randomly selected in accordance with proper statistical sampling practice unless the contrary is specifically stated.
PART 2 – SAMPLING
2.1 If a referral to the Director relates to services of a class specified in the referral (“the specified class”) that may be the subject of findings under Division 4 of Part VAA of the Act, the Commission may supply a sample (“preliminary random sample “) drawn from the services included in the referral. The preliminary random sample must contain twice the number of services worked out by reading from Table 1 the number at the intersections of:
(a) the row containing in its leftmost column (the column headed “class size”) the number of services of the specified class included in the referral; and
(b) the column headed “50%”.
2.2 If the Committee proposes to make a finding based on statistical sampling, the Committee must examine a sample of 30 services (“exploratory sample”) from the preliminary random sample and determine whether each of those services constitutes inappropriate practice or not. The Committee must then calculate the percentage of services in the exploratory sample that constitute inappropriate practice and round down the result to the next lower multiple of 5%.
2.3 If the percentage worked out in the way set out in clause 2.2 (“rounded percentage”) is less than 20%, no further statistical inferences are to be made concerning the referral.
2.4 If the rounded percentage is 20% or greater, the Committee must examine further cases from the preliminary random sample until it has examined the number of cases found in Table 1 at the intersection of:
(a) the row containing in its leftmost column (the column headed “class size”0) the number of services of the specified class included in the referral; and
(b) the column headed by the rounded percentage.
This sample (“final random sample”) may include the services that were included in the exploratory sample.
2.5 The Committee must determine whether each service included in the final random sample constitutes inappropriate practice, and work out the percentage of services in that sample that constitutes inappropriate practice.
Professional Services Review Scheme – Directions as to Sampling
2.6 The percentage worked out in the way described in clause 2.5 must then be reduced by ten percentage points. The resulting percentage must be taken to be the percentage of services of the same kind as the services included in the referral that constitute inappropriate practice.
[NOTE: Call the percentage worked out as set out in clause 2.5 “x”. To a confidence level of 95%, the percentage of services in the sample that constitutes inappropriate practice is within the interval (x ± 10)%. For the purposes of the Committee’s findings, the lower limit of that interval is to be taken.]
PART 3 – INCREASING THE SAMPLE SIZE
3.1 If a Committee proposes to make findings based o the final random sample of services, and the person under review requests that the sample size be increased, the Committee must select from the preliminary random sample a further sample containing the same number of cases as the number of cases that was included in the final random sample used in the committee’s first consideration of the referral. The latter sample is to be combined with the final random sample to make up the ‘double final random sample”.
3.2 The Committee must determine whether each service included in the doubled final random sample constitutes inappropriate practice, and work out the percentage of services in that sample that constitutes inappropriate practice.
3.3 The percentage worked out in the way described in clause 3.2 must then be reduced by half the number of percentage points found in Table 2 at the intersection of:
(a) the row containing in its leftmost column (the column headed “class size”) the number of services of the specified class included in the referral; and
(b) the column headed by the percentage calculated in clause 3.2 rounded down to the next lower multiple of 5%.
The resulting percentage must be taken to be the percentage of the services included in the referral that constitute inappropriate practice.
[NOTES:
Professional Services Review Scheme – Directions as to Sampling
Assume the Commission includes in its referral 500 surgical excisions under the same item number. It will also include 168 of those excisions randomly selected – 84 being the size of the random sample necessary to predict with 95% confidence that a result derived from the sample will be within ±10% of the actual position in the population at a hypothesised incidence of inappropriate practice of 50% (the incidence requiring the largest sample).
The Committee will consider the first 30 such services (the exploratory sample) and make a finding as to what number, if any, of those services were inappropriate.
If the Committee decides that less than 20% (6 excisions) were inappropriate, no conclusion can be drawn as the result will not be statistically valid.
If the committee decides that 6 or more of the services were inappropriate, say 8 or 26.7%, the 26.7% is rounded down to the nearest 5%, that is 25%. From Table 1, a sample size of 66 is determined.
The Committee then considers a further 36 excisions from the random sample (the number needed to make up the final random sample) and if it finds that 18 or 27% of the 66 services it has now considered were inappropriate, it can find that 17% (27% minus the possible 10% error) or 85 of the excisions were inappropriate.
At this point the practitioner has effectively three options:
PART 4 – REVOCATION
4.1 The Directions entitled “Professional Services Review Scheme – Directions as to Sampling”¹, issued under section 106K of the Health Insurance Act 1973 on 9 May 1994, are revoked.
[NOTE:
Professional Services Review Scheme – Directions as to Sampling
TABLE 1
SAMPLE SIZES FOR A 95% CONFIDENCE INTERVAL
OF ± 10%
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td style="width:31.9pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.28pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:10.5pt"><span>Class</span></p><p style="text-align:right; font-size:10.5pt"><span>size</span></p></td><td style="width:21.3pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.28pt; vertical-align:top"><p style="font-size:10.5pt"><span></span></p></td><td style="width:21.2pt; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:10.5pt"><span></span></p></td><td colspan="11" style="width:285.15pt; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:center; font-size:10.5pt"><span>Percentages of services that represent inappropriate practice</span></p></td><td style="width:20.6pt; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:10.5pt"><span></span></p></td><td style="width:22pt; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:10.5pt"><span></span></p></td></tr><tr><td style="width:31.9pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.28pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:10.5pt"><span></span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.28pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">20%</span></p></td><td style="width:21.2pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">25%</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">30%</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">35 %</span><span style="font-family:'Times New Roman Condensed', serif"></span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.28pt; padding-left:2.65pt; vertical-align:top"><p style="text-indent:2.65pt; text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">40%</span></p></td><td style="width:20.6pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.28pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">45%</span></p></td><td style="width:20.6pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">50%</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">55%</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="margin-right:3.1pt; text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">60%</span></p></td><td style="width:21.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.28pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">65%</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.28pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">70%</span></p></td><td style="width:20.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">75%</span></p></td><td style="width:21.05pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">80%</span></p></td><td style="width:20.6pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">85%</span></p></td><td style="width:22pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">90%</span></p></td></tr><tr><td style="width:31.9pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:2.28pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">50</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.28pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">29</span></p></td><td style="width:21.2pt; border-top:0.75pt solid #000000; padding-right:2.65pt; padding-left:2.65pt; vertical-align:top"><p style="text-align:right; font-size:9pt"><span style="font-family:'Times New Roman Condensed', serif">30</span></p></td><td style="width:21.3pt; border-top:0.75pt solid #000000; padding-right:2.65pt; padding-left
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