PSR Director's Update for August 2019

Published date

17 September 2019

A. Director’s Section 92 agreements effective in August 2019

The following agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect:

An agreement with a general practitioner.

The practitioner billed MBS items 23, 36 and 44 in excess of 99 percent of their peers during the year under review. The practitioner also rendered a prescribed pattern of services (the 80/20 rule) by providing 80 or more professional attendance on 36 days during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 36, 44, 721, 723, 732, 31363, 56223, 56507, 57341, 66596, 66833 and 66839, PBS items 8254K, and provision of a prescribed pattern of services and had no concerns in relation to MBS items 31363, 57341 and 66833, and PBS items 8254K.

The Director had persisting concerns that

the practitioner did not keep adequate clinical records;
MBS requirements were not always met;
the practitioner did not always provide adequate clinical input;
diagnostic imaging and pathology services were initiated without clinical indication; and
there were no exceptional circumstances causing the 80/20 rule to be breached.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $370,000, to be disqualified from providing MBS items 721, 723, 732 for 6 months, and will be reprimanded by the Director.

An agreement with a haematologist.

The practitioner billed over 40,000 services during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 13706, 13757, 13915 and 13942. The Director had persisting concerns that:

MBS requirements were not met;
services were not clinically indicated; and
the medical records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $1,400,000, to be disqualified from providing MBS items 132, 133, 13942 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner (OMP).

The practitioner billed MBS items 36, 44 and 2507 in excess of 99 percent of their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 36, 44, 703, 705, 715, 721, 723, 732 and 2715, and PBS items 8254K, and had no concerns in relation to PBS items 8254K. The Director had persisting concerns that:

MBS requirements were not always met for services rendered, including time requirements (where applicable);
records were inadequate; and
the practitioner did not provide adequate clinical input.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $420,000, to be disqualified from providing MBS items 44, 703, 705, 721, 723, 732 for 12 months, to be disqualified from providing MBS items 36 for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed in excess of 87 percent of their peers despite having a patient load on the 34th centile during the year under review. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 707, 715, 721, 723, 732, 900, 2525, 2552 and 10997. The Director had persisting concerns that:

patients were not always in attendance when the practitioner provided health assessment, chronic disease management and care plan services;
the practitioner spread billing of Medicare items across multiple days to avoid restrictions on billing certain items in association;
MBS requirements were not always met;
the medial records the practitioner kept were inadequate;
the practitioner did not always provide adequate clinical input into services that the practitioner billed.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $500,000, to be disqualified from providing all services in respect of which an MBS benefit would be payable for 36 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed MBS items 36, 44 and 5060 in excess of 99 percent of their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 36, 44, 5040 and 5060, and PBS items 3162K and 8935G. The Director had persisting concerns that:

MBS requirements were not always met, including relevant time requirements;
the practitioner did not always render MBS items 5040 and 5060 in the after-hours period;
the practitioner did not always keep adequate records of services;
the practitioner did not adequately manage patients on drugs of addition; and
the practitioner did not always provide adequate clinical input.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $290,000, to be disqualified from providing MBS items 44, 5040, 5060 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed in excess of 96 percent of their peers despite having a patient load on the 46th centile during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 705, 721, 723, 732 and 11700, and PBS items 2089Y, 2622B, 3133X, 3162K, 8254K and 8611F. The Director had persisting concerns that

records were inadequate;
MBS and PBS requirements were not always met;
services were provided without appropriate clinical indication;
the practitioner’s clinical input was inadequate; and
the practitioner’s management of some patients was inappropriate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $270,000, to be disqualified from providing MBS items 723, 11700 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed over 15,000 services during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 705, 721, 723, 732 and 5020, and PBS items 1654C, 1655D, 2089Y, 3133X, 3162K, 8387K and 8524P, and had no concerns in relation to MBS item 705. In relation to the remaining items, the Director had persisting concerns that:

the practitioner did not always keep adequate medical records;
the MBS requirements were not always met;
the practitioner did not always provide adequate clinical input;
CDM services were not adequately individualised;
the practitioner prescribed opioids and benzodiazepines where there was not always evidence supporting the clinical indication and non-pharmaceutical methods were not adequately pursued; and
the practitioner prescribed opioids and benzodiazepines without adequately considering side effects or risks of addiction and without appropriately managing patient use.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing the MBS items of concern. The practitioner agreed to repay $280,000, to be disqualified from providing MBS items 721, 723, 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed over 16,000 services during the year under review. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 703, 721, 723, 732, 2715 and 5020, and had no concerns in relation to MBS items 23 and 5020. The Director had persisting concerns that:

MBS item requirements were not met for all services, including minimum time requirements (where relevant);
medical records were inadequate; and
not all services were clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $120,000, to be disqualified from providing MBS items 703, 721, 723, 732, 2715 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed MBS items 721, 723 and 732 in excess of 99 percent of their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 3, 23, 707, 721, 723, 732, 2700 and 2713, and PBS items 2089Y, 2622B and 3162K. The Director had persisting concerns that

the practitioner kept inadequate records for all reviewed services;
the practitioner billed level A (MBS item 3) consultations when patients did not attend the practitioner;
the practitioner billed MBS item 23 for services that did not involve sufficient clinical complexity or duration to warrant billing the item, and may not have always complied with the item descriptor;
the practitioner did not provide adequate clinical input into health assessments (MBS item 707). In particular, the practitioner did not adequately conduct any of the tasks in the item descriptor or appropriately act on information collected by the practice nurse;
the practitioner provided CDM services to patients who did not have an eligible chronic disease and otherwise did not comply with the item descriptors when rendering these items;
the practitioner did not adequately consult with at least two collaborating providers when rendering MBS item 723 or conducting reviews of this item under MBS item 732;
the practitioner did not comply with the item descriptors, adequately document, or provide adequate clinical input in connection with rendering mental health services (MBS items 2700 and 2713) and
the practitioner prescribed temazepam, oxycodone and diazepam in circumstances that were not clinically appropriate, with inadequate clinical oversight or patient management, and otherwise did not provide sufficient clinical input when prescribing these medications.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $325,000, to be disqualified from providing MBS items 707, 721, 723, 732, 2700 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed MBS items 721, 723 and 732 in excess of 98 percent of their peers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 44, 707, 721, 723, 732 and 2195. The Director had persisting concerns that:

MBS item requirements were not met, including the minimum time requirements for MBS items 44, 707 and 2195;
records are inadequate;
some services were not clinically indicated, including CDM services and those with minimum time requirements; and
clinical input was inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $90,000, to be disqualified from providing MBS items 2195 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed over 18,000 services during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 36, 597, 705, 707, 715, 721, 723, 732, 2713, 2717 and 5020, and PBS items 1215Y, 1916W, 2622B and 3162K. The Director had persisting concerns that:

MBS requirements were not met for all services, including minimum time requirements (where relevant);
medical records were inadequate;
not all services were clinically indicated; and
not all prescribing under the PBS was clinically indicated and in some cases PBS restrictions were not met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $775,000, to be disqualified from providing MBS items 585, 705, 707, 715, 721, 723, 732, 2717 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in August 2019.

C. Federal Court

No decisions from the Federal Court were handed down in August 2019.

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

No matters were referred to the major non-compliance (fraud) division in August 2019.

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in August 2019.