PSR Director's Update for April 2022

Published date

10 May 2022

A. Director’s Section 92 agreements effective in April 2022

Ten agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in April 2022.

An agreement with a radiologist

During the review period, the practitioner billed Medicare Benefits Schedule (MBS) items 11602 and 55244 in association and a number of Magnetic Resonance Imaging (MRI) items in excess of 96% of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 11602, 55054, 55244, 55848, 57341, 63001, 63040, 63049, 63055, 63070, 63161, 63167, 63173, 63176 and 63182. The Director had persisting concerns that:

for MBS item 104, contrary to the MBS requirements:
- the practitioner billed this personal attendance item where another practitioner had attended the patient
- the item was routinely co-billed together with a procedural or interventional service (MBS items 55054, 55848, 57341) when the specialist attendance was covered by the procedural item, and there was no evidence of a separate specialist consultation service having been performed
- there was no referral requesting a specialist consultation
MBS items 11602 and 55244 were co-billed when a deep vein thrombosis (DVT) study was performed, however the records only show a single DVT study was requested, performed and reported
MRI brain items (MBS items 63001, 63040, 63049, 63055 and 63070) were regularly co-billed where not all services billed were requested or otherwise clinically indicated and a complete service was not performed for all co-billed items
MRI spine items (MBS items 63161, 63167, 63173, 63176 and 63182) were regularly co-billed where not all services billed were requested or otherwise clinically indicated and a complete service was not performed for all co-billed items
the practitioner’s records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 104, 11602, 55054, 55244, 55848, 57341, 63001, 63040, 63049, 63055, 63070, 63161, 63167, 63173, 63176 and 63182. The practitioner agreed to repay $160,000, to be disqualified from providing MBS items 104, 91822, 91832 and 11602 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 91822 and 91832 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a neurologist

During the review period, the practitioner billed MBS items 11018, 11021 and 11024 in association, and with attendance MBS item 133 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 11012, 11018, 11021, 11024, 18360 and 18377. The Director had persisting concerns that:

for MBS items 116 and 133 services the practitioner’s records were not always adequate and contemporaneous
the MBS requirements for items 132, 133, 11012 and 11024 services were not always met, including the minimum time requirements for MBS items 116 and 133
MBS items 11018 and 11021 services were not always clinically indicated
MBS item 18360 was billed multiple times for injection into the same muscle with the same motor nerve, which is inconsistent with the MBS item descriptor
some diagnostic procedures and investigations, including MBS item 11018 were duplicated or performed over multiple days, with each day being separately billed to Medicare
the records were generally inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 116, 132, 133, 11012, 11018, 11021, 11024 and 18360. The practitioner agreed to repay $310,000, to be disqualified from providing MBS items 132, 133, 11012, 11024, 92422, 92423, 92431 and 92432 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92422, 92423, 92431 and 92432 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a radiologist

During the review period, the practitioner billed MRI services in association in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 18232, 55848, 57341, 63001, 63007, 63040, 63046, and 63064. The Director had persisting concerns in respect of MBS items 104, 105 and 63064 that:

for MBS item 104 and 105, contrary to the MBS requirements:
- the practitioner had billed these personal attendance items where another practitioner had attended the patient
- these attendance items were inappropriately co-billed with a procedural or interventional service where the attendance was a necessary part of the procedure item claimed and there was never a record of a consultation service or a consultation separate from the procedure having been performed
- there was no referral requesting a specialist consultation
MBS item 63064 was co-billed with other MRI brain items where a single service only was requested and indicated and a single indication performed and reported on
informed consent was either not obtained or not adequately documented for some procedures.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing items 104, 105 and 63064. The practitioner agreed to repay $65,000, to be disqualified from providing MBS items 104, 105, 91822, 91823, 91832 and 91833 for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 91822, 91823, 91832 and 91833 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered a high volume of both total and daily services and prescribed Pharmaceutical Benefits Scheme (PBS) items 2622B, 8008L, 8601Q, 8865N and 8866P in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 5028, 5049, 90035 and 90043 and prescribing of PBS items 2622B, 8008L, 8601Q, 8865N and 8866P. The Director had persisting concerns in relation to MBS items 36, 5049 and 90043 that:

the MBS requirements were not always met in relation to Level C consultations, including minimum time requirements and the lack of a recorded detailed patient history, appropriate examinations or relevant management plans
the clinical records were almost universally inadequate to reflect what occurred during the consultations.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 5049 and 90043. The practitioner agreed to repay $110,000, to be disqualified from providing MBS items 36, 91801 and 91810 services for 6 months, and will be reprimanded by the Director. The disqualification from MBS items 91801 and 91810 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 36, 44 and 91810 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 585, 41500 and 91810 and prescribing of PBS item 8254K. The Director had persisting concerns in relation to MBS items 23, 36, 44, 585, 41500 and 91810 that:

the MBS requirements were not always met in relation to MBS items 36, 44 and 91810 services, including minimum time requirements. In addition, the practitioner’s clinical input was insufficient
the MBS requirements were not always met in relation to MBS item 41500 services as there was not always a record of a foreign body being present
the records did not indicate the patients were experiencing urgent health problems, as required by the item descriptor for MBS item 585 services
records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 585, 41500 and 91810. The practitioner agreed to repay $300,000, to be disqualified from providing MBS items 44, 41500, 91811 and 91802 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 91811 and 91802 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a radiologist

During the review period, the practitioner co-claimed spine MRI services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 30224, 55054, 55848, 57341, 57521, 57527, 57712, 57715, 58108, 63161, 63167, 63173, and 63176. The Director had no persisting concerns in relation to MBS items 57521 and 63161. The Director had persisting concerns that:

for MBS item 104:
- the practitioner billed this personal attendance item where another practitioner had attended the patient
- there was no evidence of a separate specialist consultation service having been performed distinct from the co-billed investigation or procedure service
multiple X-ray and MRI items were co-billed including where a single service was performed and reported, and where not all the services billed were requested or clinically indicated
the practitioner’s records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing items 104, 30224, 55054, 55848, 57341, 57527, 57712, 57715, 58108, 63167, 63173 and 63176. The practitioner agreed to repay $280,000 and be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723, 732, 11315 and 12003 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 11315, 12003, 66596, 66833 and 92072 and prescribing of PBS items 1169M, 2089Y and 2253N. The Director had no persisting concerns regarding MBS item 11315. The Director had persisting concerns that:

the MBS requirements were not met
it was unclear whether patients were present when services were provided and/or the services may not have taken place
the practitioner’s clinical input was inadequate
it was not clear that all pathology services requested were clinically indicated
the records produced by the practitioner were inadequate and non-contemporaneous, including that a significant majority of the records included notes that were written or amended in response to the review and in some instances years after the date on which the service was billed.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS items 36, 721, 723, 732, 12003, 66596, 66833 and 92072 and prescribing PBS items 1169M, 2089Y and 2253N. The practitioner agreed to repay $400,000, to be disqualified from providing all services in respect of which an MBS benefit would be payable for 3 months, and to be disqualified from providing MBS items 36, 721, 723, 732, 12003, 66596, 92072, 91801, 92024, 92025 and 92028 services for 12 months. The practitioner also agreed to be reprimanded by the Director. The disqualification from MBS items 92028, 92025, 92024, 91801 and 92072 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723, 732, 92068, 92069 and 92072 in excess of 95% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 92068, 92069 and 92072. The Director had persisting concerns that:

the MBS requirements were not always met. For example, services billed as MBS items 23 and 36 reflected straightforward consultations not consistent with Level B or C attendances respectively
the records relating to Chronic Disease Management (CDM) services were overly reliant on templates that had not been individualised to the patient and did not reflect that sufficient clinical input was provided into each service
the majority of reviewed plans billed under MBS items 721and 92068 were not comprehensive and had the same generic management goals and actions and/or auto-populated information appearing
in relation to MBS item 723 and 92069 services there was not always consultation with at least two other healthcare providers participating in the patients' care
the practitioner’s records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering these items of concern. The practitioner agreed to repay $115,000, to be disqualified from providing MBS items 36, 91801, 91810, 92024 and 92068 services for a period of 12 months, and will be reprimanded by the Director. The disqualification from MBS items 91801, 91810 and 92024 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723 and 732 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 732, 5020 and 91809. The Director had persisting concerns that:

the MBS requirements were not always met. For example, for CDM items, the plans were not comprehensive or sufficiently personalised, and team care arrangements did not involve at least two other healthcare providers where applicable
the records relating to CDM services were overly reliant on templates that had not been individualised to the patient and did not reflect that sufficient clinical input was provided into each service
the records relating to level B attendances were inadequate. For example, the records for MBS items 23, 5020 and 91809 services were generally brief, with some entries failing to record important clinical information.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering these items of concern. The practitioner agreed to repay $200,000, to be disqualified from providing MBS items 721, 723, 732, 92024, 92025 and 92028 services for a period of 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92024, 9025 and 92028 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner prescribed PBS items 2363J, 8525Q and 6162K in excess of 95% of their peers and rendered high daily volumes of MBS services. The Director reviewed this practitioner’s rendering of MBS items 23 and 36, and prescribing of PBS items 1215Y, 2363J, 2622B and 8525Q. The Director had no persisting concerns in relation to PBS item 1215Y. The Director had persisting concerns that:

the MBS requirements, in particular time requirements, were not always met (where relevant) and the records reflected brief services that did not always warrant Level B or C services respectively
the prescribing of PBS items 2363J, 2622B and 8525Q was not always clinically indicated and insufficient clinical input was provided into prescribing these medications
patients to whom PBS items 2363J, 2622B and 8525Q were prescribed were not appropriately managed
PBS requirements were not always met as medications were prescribed outside of their approved PBS clinical indication
the records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23 and 36, and prescribing PBS items 2363J, 2622B and 8525Q. The practitioner agreed to repay $20,000, to be disqualified from providing all services in respect of which an MBS benefit would be payable for 3 years, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations came into effect in April 2022.

C. Federal Court

No decisions concerning PSR were handed down in April 2022.

D. Referrals to the major non-compliance (fraud) division (89A & 106N)

No matters were referred to the major non-compliance (fraud) division in April 2022.

E. Referrals to AHPRA (106XA/B)

Three matters were referred to AHPRA in April 2022.