PSR Director's Update for December 2019

Published date

10 January 2020

A. Director’s Section 92 agreements effective in December 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 Medicare Benefits Schedule (MBS) items 721 and 723 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723 and 732. The Director had persisting concerns that the:

practitioner did not keep adequate medical records of the services they provided;
practitioner did not record medications prescribed or retain copies of specialist reports, referrals and investigation results;
documents for most chronic disease item services were absent;
MBS requirements were not always met; and
practitioner did not provide sufficient clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $300,000, to be disqualified from providing MBS items 23, 721, 723 and 732 for 36 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed a large volume of daily services during the review period, including more than 60 professional attendances on more than 80 occasions. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 2713, 5040 and 56001, and Pharmaceutical Benefits Scheme (PBS) items 1215Y and 3119E, and had no concerns in relation to MBS items 23 and 56001, or the PBS items. The Director had persisting concerns in relation to the remaining MBS items that the:

MBS requirements for these items were not always met, including the minimum time requirements where relevant;
practitioner did not always keep adequate records of the services provided; and
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 $280,000, to be disqualified from providing MBS items 36, 44 and 5040 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed more than 20,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 35, 731, 903, 5028, 5049 and 5067, and PBS items 2089Y, 2622B, 3132W, 8000C, 8865N and 8866P, and had no concerns in relation to PBS items 2089Y, 2622B, 8000C, 8865N and 8866P. The Director had persisting concerns that:

MBS requirements were not met, including minimum time requirements (where applicable);
the practitioner’s records are inadequate and non-contemporaneous; and
the practitioner prescribed schedule 4 and 8 medication on an ongoing basis without reviewing their clinical necessity.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $700,000, to be disqualified from providing MBS items 35, 731 and 903 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed Medicare Benefits Schedule (MBS) items 703, 721 and 723 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 44, 703, 721, 723 and 732, and PBS item 8254K. The Director had persisting concerns that:

the MBS requirements were not always met, including by performing tasks specified in relevant descriptors and meeting minimum time requirements, where relevant;
the practitioner’s clinical input was inadequate;
regarding chronic disease management services, the practitioner did not always prepare relevant document with appropriate individualised goals, communicate and consult appropriately with collaborating providers or meaningfully conduct clinically relevant reviews;
the practitioner’s records were inadequate; and
the practitioner prescribed PBS item 8254K outside of PBS restrictions to patients who did not have suspected or proven resistance to amoxicillin.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $220,000, to be disqualified from providing MBS items 44 and 703 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed a large volume of daily services during the review period, including more than 60 professional attendances on more than 60 occasions. The Director reviewed this practitioner’s rendering of MBS items 23, 705, 721, 723, 732, 11610, 11700, 41647, 56223, 56507, 66719 and 69333, and PBS item 8254K. The Director had persisting concerns that the:

medical records are inadequate;
practitioner did not provide sufficient clinical input into some of the services;
practitioner rendered or initiated diagnostic procedures and investigations and pathology items without documented clinical indication;
MBS requirements were not always met; and
practitioner prescribed amoxicillin and clavulanic acid outside PBS restrictions.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $400,000, to be disqualified from providing MBS items 705, 721, 723, 732, 11610, 11700, 41647, 56223, 56507, 66719 and 69333 for 12 months, and will be reprimanded by the Director.

An agreement with an optometrist.

The optometrist billed a large volume of daily services during the review period, including more than 30 services on more than 20 occasions. The Director reviewed this practitioner’s rendering of MBS items 10910, 10911, 10914, 10915 and 10918, and had no concerns in relation to MBS item 10915. The Director had persisting concerns that:

the MBS item requirements were not always met;
the medical records were inadequate;
not all services were clinically indicated; and
clinical management was not always appropriate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $80,000, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed a large volume of daily services during the review period, including more than 60 services on more than 160 occasions. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 585, 597, 721, 723, 732, 5020 and 30195, and PBS items 1215Y, 2622B, 3162K, 8254K and 8611F. The Director had persisting concerns that the:

medical records are inadequate;
practitioner did not provide sufficient clinical input into some of the services;
MBS requirements were not always met;
practitioner prescribed drugs of dependence 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; and
practitioner prescribed amoxicillin and clavulanic acid outside the PBS restriction.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $785,000, to be disqualified from providing MBS items 36, 585, 721, 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed more than 17,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 160, 161, 721, 723, 2713, 5020, 11710 and 30185, and had no concerns in relation to MBS item 30185. The Director had persisting concerns that:

the practitioner did not keep adequate medical records for services provided;
the MBS requirements for services provided were not always met, including minimum time requirements where relevant;
chronic disease management services may have been billed without the knowledge or consent of the patient;
the practitioner did not always provide adequate clinical input; and
in some services rendered, the practitioner ordered tests or referrals that were not, on the face of the record, clinically relevant.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $180,000, to be disqualified from providing MBS items 161, 721, 723 and 2713 for 12 months, and will be reprimanded by the Director.

An agreement with an optometrist.

The optometrist billed a large volume of daily services during the review period, including more than 30 services on more than 70 occasions. The Director reviewed this practitioner’s rendering of MBS items 10910, 10913, 10914, 10915, 10916 and 10918, and had no concerns in relation to MBS items 10910, 10916 and 10918. In relation to the remaining items, the Director had persisting concerns that the:

practitioner’s records are inadequate; and
MBS item descriptor was not always met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $30,000, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed more than 13,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 2713, 2715, 5020, 10997, 11610, 41677, 56223, 66596, 66833 and 66839, and had no concerns in relation to MBS item 56223. The Director had persisting concerns that the:

MBS requirements for these items were not always met, including the minimum time requirements where relevant;
practitioner did not always keep adequate records of the services provided;
practitioner initiated pathology investigations without a documented clinical indication; and
practitioner did not always provide adequate clinical input into each service.

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 721, 723, 732, 2715, 11610, 10997 and 41677 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner (OMP).

The practitioner billed MBS item 591 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 591 and 597. The Director had persisting concerns that the:

MBS requirements were not always met, in particular the requirements for determining urgency as relevant for each item during the review period;
medical records are inadequate;
practitioner did not always provide sufficient clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $70,000, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in December 2019.

C. Federal Court

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

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

One matter was referred to the major non-compliance (fraud) division in December 2019.

E. Referrals to AHPRA (106XA/B)

Three matters were referred to AHPRA in December 2019.