PSR Director's Update for August 2020

Published date

7 September 2020

A. Director’s Section 92 agreements effective in August 2020

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 psychiatrist

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) item 304 services in excess of 99 percent of their peers. The Director reviewed the practitioner’s rendering of MBS items 302, 304 and 306 and prescribing of Pharmaceutical Benefits Scheme (PBS) items 3133X and 3162K. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
attendances were provided frequently and for some patients that appeared stable, and may not always have been clinically indicated;
the clinical management of the patient was not always appropriate, including in circumstances where the practitioner prescribed benzodiazepine derivatives; and
the practitioner’s clinical records were inadequate. In particular, the practitioner did not always include a detailed or extensive patient history, a record of a mental state examination or review of symptoms, a diagnosis or any detail regarding a management plan for their patients.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $120,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered more services as MBS item 41647 than 99 percent of general practitioners. Additionally, the practitioner rendered MBS item 41647 services twice in a patient presentation on at least 96% of the occasions when they rendered the item. The Director reviewed this practitioner’s rendering of MBS items 23 and 41647. The Director had persisting concerns that:

the records were inadequate and did not always reflect a clinical indication for the service, particularly bilaterally, and where other treatment options may have been more appropriate; and
where MBS item 23 was billed in association with at least one MBS item 41647 service, the records were inadequate and did not always support the billing of both items.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing MBS item 41647, and MBS item 23 when provided to the same patient on the same day as a MBS item 41647 service. The practitioner agreed to repay $100,000, to be disqualified from providing MBS item 41647 services for 36 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 721, 723 and 732 in excess of 96 percent, 98 percent and 93 percent of their peers respectively. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 2715, 5020 and 16500 and prescribing of PBS item 8254K. The Director had no persisting concerns in relation to MBS items 5020 and 16500. The Director had persisting concerns with the remaining MBS and PBS items reviewed that:

MBS requirements, including the minimum time requirements (where relevant), were not always met;
the practitioner did not always maintain adequate records. In several reviewed cases, there was no clinical record for some of the billed services;
the practitioner did not always provide sufficient clinical input into some services; and
PBS requirements were not always met in respect of PBS item 8254K.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $140,000, to be disqualified from providing MBS items 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS items 721 and 723 in excess of 98 percent of their peers and MBS items 41647 and 11610 in excess of 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 23, 721, 723, 732, 11610, 41647, 56301, 56507, 56619, 66719 and 69303 and PBS items 10018G, 1440T and 8254K. The Director had persisting concerns that:

MBS item requirements were not always met;
the practitioner’s clinical input was often inadequate;
the medical records were inadequate. For example, the majority of the records for the reviewed chronic disease management services lacked sufficient individualisation and lacked evidence of consent. Where MBS item 723 was billed, the records did not always reflect that two way communication with other health providers had occurred;
the services were not always clinically indicated;
the prescribing was not always clinically indicated; and
the practitioner prescribed PBS medications outside of PBS restrictions.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $200,000, to be disqualified from providing MBS items 721, 723, 732, 11610 and 41647 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723 and 2717 in excess of 99 percent of their peers and MBS item 2713 on more occasions than 96 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 715, 721, 723, 2713, 2717 and 5020 and prescribing of PBS items 1215Y, 3162K and 8254K. The Director had no persisting concerns in relation to MBS items 23 and 5020. The Director had persisting concerns with the remaining items, being that:

MBS item requirements, including minimum time requirements (where relevant), were not always met;
the practitioner’s clinical input was not always adequate;
the practitioner did not always maintain adequate records;
not all the services appeared to have been clinically indicated;
there was not always a clinical indication for the prescribing of medications. For example, when prescribing PBS items 1215Y and 3162K the practitioner often failed to record reasons documenting why these medications were prescribed to treat particular conditions; and
the practitioner did not always meet the PBS restrictions when prescribing PBS item 8254K.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $150,000, to be disqualified from providing MBS item 715 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS item 36 in excess of 98 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 36, 44, 732, 2713 and 31361 and PBS item 8601Q. The Director had persisting concerns that

MBS requirements were not always met. In particular, the practitioner co-billed items where MBS item requirements were not independently met for both billed items;
not all services were clinically indicated;
the practitioner did not always maintain adequate records; and
PBS restrictions for item 8601Q were not always met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $45,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 45201, 45202, 45439, 45448, 45451 and 45665 services in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 45201, 45202, 45439, 45448, 45451 and 45665 and prescribing of PBS item 8785J. The Director had persisting concerns that:

MBS requirements were not always met;
the practitioner’s medical records were inadequate. For example, the practitioner did not always appear to document a pre-operative assessment of patients or their vitals before, during and after performing therapeutic procedures;
the practitioner did not always appropriately manage their patients;
the provision of therapeutic procedures was not always clinically indicated; and
clinical input when prescribing medications was not always adequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $115,000, to be disqualified from providing MBS items 45202, 45448 and 45665 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the total and daily services rendered by the practitioner were in excess of 98 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 705, 721, 723 and 732 and prescribing of PBS item 2622B. The Director had no persisting concerns in relation to MBS item 705. The Director had persisting concerns with the remaining items, being that:

MBS requirements were not always met. For example, in the reviewed records for chronic disease management services there was not always sufficiently individualised patient goals;
the practitioners records were inadequate;
not all services were clinically indicated; and
PBS requirements for item 2622B were not met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $200,000, to be disqualified from providing MBS item 732 for 12 months, to be disqualified from providing MBS item 36 for six months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period the practitioner provided MBS services in excess of 99 percent of their peers, despite having a patient load on the 65th percentile. The Director reviewed this practitioner’s provision of MBS items 23, 36, 721, 723, 732, 2521, 2712, 2713, 2717, 11610, 66596 and 66716 and PBS item 8254K. The Director had persisting concerns that:

MBS requirements, including minimum time requirements (where applicable), were not always met;
the practitioner’s records were not always adequate;
the practitioner billed chronic disease management services when a patient was not present;
pathology services were initiated and diagnostic procedures were performed where they were not clinically indicated; and
PBS restrictions were not always met with respect to PBS item 8254K.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $560,000, to be disqualified from providing MBS items 721, 723, 732, 2521, 2712, 2713, 2717 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner’s total number of services rendered was in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23 and 5020 and prescribing of PBS item 8254K. The Director had persisting concerns that:

MBS requirements were not always met;
the practitioner did not always provide sufficient clinical input into services;
the practitioner’s records were inadequate;
the practitioner’s prescribing of PBS item 8254K was not always clinically indicated; and
PBS restrictions were not always met with respect of PBS item 8254K.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $260,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner’s total volume of services was in excess of 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 23, 5020, 65070 and 66593. The Director had persisting concerns that:

MBS requirements were not always met;
the practitioner’s records were inadequate;
the practitioner did not always provide sufficient clinical input into services; and
the pathology ordered by the practitioner was not always clinically indicated. For example, it appeared that the practitioner often initiated pathology services for screening rather than based on a patient history or examination.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $100,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered more services as MBS items 721, 723, 732 and 2713 than at least 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 721, 723, 732, 2713, 2717 and 66596 and PBS item 8254K. The Director had persisting concerns that

the practitioner did not always maintain adequate records;
not all services were clinically indicated;
MBS item requirements were not always met;
the practitioner did not always provide adequate clinical input;
PBS restrictions were not always met with respect of PBS item 8254K; and
the practitioner prescribed antibiotics in circumstances where the medication was not clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $250,000, to be disqualified from providing MBS items 721, 723, 732, 2713 and 2717 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner provided MBS item 23, 2715, 55036, 55844, 66596 and 71079 in excess of 99 percent of their peers The Director reviewed this practitioner’s provision of MBS items 23, 2715, 55036, 66596, 66653 and 66655, and PBS items 3095X, 3162K and 8318T. The Director had persisting concerns that

MBS requirements, including minimum time requirements (where applicable), were not always met;
the practitioner did not always maintain adequate records;
there was not always a clinical indication for pathology services or diagnostic procedures; and
the practitioner’s prescribing of PBS items 3095X, 3162K and 8318T was not always clinically appropriate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $269,568, to be disqualified from providing MBS items 2715 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered skin flap procedure services and mental health services at a variance to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 2713, 45202 and 45206 and prescribing of PBS items 2363J, 2622B and 3162K. The Director had persisting concerns that:

the practitioner did not always provide appropriate clinical management of patients;
the practitioner did not always maintain adequate clinical records;
MBS requirements were not always met for all services;
there was not always a clinical indication for each service;
the practitioner did not always comply with the PBS restrictions for items 2363K and 2622B;
the practitioner’s prescribing was not always clinically indicated; and
the practitioner did not always provide sufficient clinical input when prescribing.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $50,000, to be disqualified from providing all services in respect of which a MBS benefit would be payable for 36 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721 and 732 on more occasions than 98 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723 and 732. The Director had persisting concerns that:

the MBS requirements were not always met;
the practitioner’s records were inadequate; and
patients were not always in attendance when Chronic Disease Management items were rendered.

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 item 723 for 18 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in August 2020.

C. Federal Court

No decisions from the Federal Court were handed down in August 2020.

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

No matters were referred to the major non-compliance (fraud) division in August 2020.

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in August 2020.