PSR Director's Update for July and August 2022

Published date

29 September 2022

A. Director’s Section 92 agreements effective in July and August 2022

Eight agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in July/August 2022.

An agreement with a Medical Practitioner

During the review period, the practitioner provided Medicare Benefits Schedule (MBS) items 705, 723, 2713, 30003, 30026, 30061, 30219 and initiated MBS items 55848 and 57241 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering and initiation of MBS items 705, 715, 721, 723, 732, 2713, 30003, 30026, 30061, 30219, 31356, 47904 and 56223. The Director also reviewed this practitioner’s prescribing of Pharmaceutical Benefits Scheme (PBS) items 8016X, 8254K and 11379X. The Director had no persisting concerns in relation to MBS items 30219, 31356 and 56223. In relation to the remaining items, the Director had persisting concerns that:

the MBS requirements were not always met. For example, there was a lack of a basic preventive health care management plan required for MBS item 705
the practitioner did not always provide adequate clinical input, for example there was not always an adequate examination of the patient when rendering MBS item 715
the practitioner’s medical records were not always adequate, relying heavily on templates and autopopulated text which were not individualised
not all services rendered by the practitioner were clinically indicated. For example, it was not always clear that the patient presented with a localised burn when MBS item 30003 was rendered
the practitioner did not always meet the PBS requirements when prescribing PBS items. For example, there was not always a bacterial infection when prescribing under PBS item 8016X and or actual or suspected resistance to amoxicillin when prescribing under PBS items 8254K
the practitioner’s clinical management of patients to whom medication was prescribed was inadequate , in particular for patients with chronic obstructive pulmonary disorder and asthma.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS items 705, 715, 721, 723, 732, 2713, 30003, 30026, 30061 and 47904 services and prescribing PBS items 8016X, 8254K and 11379X. The practitioner agreed to repay $200,000, to be disqualified from providing MBS items 705, 715, 721, 723, 732, 92004, 92016, 92024, 92068, 92025, 92069, 92028 and 92072 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92004, 92016, 92024, 92068, 92025, 92069, 92028 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 3 and 10997 services in excess of 99% of their peers and rendered MBS item 723 and 732 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 3, 721, 723, 732, 10997 and 11700. The Director had no persisting concerns in relation to MBS item 11700. The Director had persisting concerns in relation to the other items that:

the practitioner’s records were not always adequate for Chronic Disease Management (CDM) services
the MBS requirements were not met. For example, documents for CDM services were not always comprehensive plans or adequate arrangements or reviews individualised for managing patients’ chronic conditions
for MBS item 3 services, there were instances where there was no indication the patient was present at the consultation
there was not always a clinical indication for CDM services. For example, some patients were not eligible for CDM services as they did not have a chronic or terminal medical condition
some services billed as MBS item 10997 were not sufficiently connected with the patient’s management plans or team care arrangements

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 3, 721, 723, 732 and 10997. The practitioner agreed to repay $90,000 and will be reprimanded by the Director.

An agreement with a Radiologist

During the review period, the practitioner rendered MBS items 56107, 56412, 56625, 57007, 61523 and 61598 services in excess of 99% of their peers and rendered MBS item 104 in a volume disproportionate to their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 56107, 56625, 61523 and MBS items 56412, 57007 and 56107 when billed in association. The Director had persisting concerns that:

in relation to MBS item 104, there was no evidence of a separate attendance when co-billed with a therapeutic procedure item, there was no clinical relevance to billing this item and the practitioner did not keep adequate and contemporaneous records
in relation to MBS item 61523, MBS requirements were not met where a positron emission tomography (PET) scan was performed. It was not evident that nodules were unsuitable for biopsy or that investigation by biopsy had not been effective
in relation to MBS items 56625 and 56107, and MBS items 56107, 56412 and 57007 when billed in association, there were no clinical indication for the computerised tomography (CT) scans.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 104, 56107, 56625 and 61523, and MBS items 56107, 56412 and 57007 when billed in association. The practitioner agreed to repay $93,000 and will be reprimanded by the Director.

An agreement with a General Practitioner

During the review period, the practitioner rendered a volume of daily services disproportionate to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 585, 721, 723, 732 and 30192. The Director had no persisting concerns in relation to MBS item 585. The Director had persisting concerns in relation to the remaining items that:

the practitioner’s record keeping was inadequate. For example, progress notes often contained autopopulated text with insufficient content and detail and content not specific to the patient
the practitioner did not always provide sufficient clinical input into services rendered
the MBS requirements where not always met. For example, there was often no evidence of collaboration with two other providers when Team Care Arrangement plans were prepared

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 721, 723, 732 and 30192. The practitioner agreed to repay $245,000, to be disqualified from providing MBS items 721, 723, 732, 92024, 92025 and 92028 services 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 703 and 723 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 703, 705, 707, 721 and 723. The Director had persisting concerns that:

MBS requirements were not always met, including the minimum time requirements
the practitioner’s records were not always adequate
the practitioner did not always provide sufficient clinical input. For example, when managing chronic conditions, it was not always clear from the records that the practitioner managed or addressed patient conditions appropriately

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 703, 705, 707, 721 and 723. 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 total and daily services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 5020, 5040, 91809 individually and CDM items (being MBS items 721, 723, 732, 92068 and 92069). The Director had no concerns in relation to MBS items 23 and 5040. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met, including the minimum time requirements
the practitioner did not always provide sufficient clinical input
the practitioner’s records were not always adequate

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 721, 723, 732, 5020, 91809, 92068 and 92069. The practitioner agreed to repay $39,000 and will be reprimanded by the Director. The disqualification from MBS item 91809 reflects disqualification from an equivalent telehealth item.

An agreement with a Medical Practitioner

During the review period, the practitioner rendered a volume of daily services disproportionate to their peers. . The Director reviewed this practitioner’s rendering of MBS items 53, 54, 57, 282, 5203, 5207, 5208, 91812, 91813 and 91814. The Director had no persisting concerns in relation to MBS items 53, 5203 and 91812. In relation to the remaining items, the Director had persisting concerns that:

MBS requirements were not always met, including the minimum time requirements
the practitioner provided insufficient clinical input based on the records
the practitioner’s records were inadequate. For example, templates and autopopulated entries were heavily relied upon, making it difficult to ascertain that the records reflected what had occurred during the consultation

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 54, 57, 282, 5207, 5208, 91813 and 91814. The practitioner agreed to repay $90,000 and will be reprimanded by the Director.

An agreement with a Neurologist

During the review period, the practitioner rendered MBS items 132 and 133 services in excess of 99% and 97% of their peers respectively. The Director reviewed this practitioner’s rendering of MBS items 132, 133, 11024 and 11300. The Director had no persisting concerns in relation to MBS items 11024 and 11300. In relation to MBS items 132 and 133, the Director had persisting concerns that:

MBS requirements were not always met, including the minimum time requirements and inclusion of a comprehensive multi or detailed single organ system assessment in treatment and management plans
the practitioner’s record were inadequate
services were not always clinically indicated. For example, it was not always clear that patients had at least two morbidities that warranted a treatment and management plan of significant complexity

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 132 and 133. The practitioner agreed to repay $42,000 and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations came into effect in July/August 2022

PSRC 1313

On 2 August 2022 a final determination came into effect regarding a nurse practitioner. The practitioner was directed to:

be reprimanded
be counselled
repay $431,827.06 to the Commonwealth
be disqualified from rendering MBS items 82210, 91179 and 91190 for a period of 9 months and MBS items 82215, 91180 and 91191 for a period of 12 months

The directions resulted from a final report of a PSR Committee, which found that the practitioner had engaged in inappropriate practice in connection with services rendered as MBS items 82210 and 82115.

In relation to both those items, the Committee made findings of inappropriate practice on the basis of one or more of the following:

The MBS requirements were not met, including as to minimum time requirements
Medical records were inadequate
The clinical input was inadequate
Phlebotomy, where clinical indication had been determined and pathology had been initiated by a medical practitioner, was not in all cases appropriately claimed as part of an MBS item 82210 or 82215 service.

The disqualification from MBS item 91179, 91180, 91190 and 91191 reflects disqualification from equivalent telehealth items where applicable.

PSRC 1396

On 2 August 2022 a final determination came into effect regarding a general practitioner. The practitioner was directed to:

be reprimanded
be counselled
repay $424,965.02 to the Commonwealth and
be disqualified from rendering MBS items 721, 723, 92024 and 92025 services for 12 months.

These directions followed a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with the rendering of MBS item 23, 721 and 723 and the initiation of MBS items 66716 and 66900.

In relation to MBS item 23, the Committee made findings of inappropriate practice on the basis of one or more of the following:

the MBS requirements were not met
the practitioner’s clinical input was inadequate
the medical record was inadequate

In relation to MBS item 721 and 723, the Committee made findings of inappropriate practice on the basis of one or more of the following:

the patient did not attend on the date of service and/or the General Practitioner Management Plan (GPMP) or Team Care Arrangement (TCA) was not prepared on the date of service
the MBS item requirements were not met, including that the service was not comprehensive or individualised to the patient and the service was not provided in respect of a chronic or terminal condition; in respect of the TCA there was not collaboration with at least two other providers
the practitioner’s clinical input was inadequate
the medical record was inadequate.

In relation to the initiation of MBS item 66716 and 66900:

the ordering of Thyroid-Stimulating Hormone quantitation was not clinically indicated
the practitioner’s clinical input into the service and management of the patient was inadequate
the medical record was inadequate, including in demonstrating the rationale for the initiation of the pathology.

The disqualification from MBS item 92024 and 92025 reflects disqualification from equivalent telehealth items where applicable.

C. Federal Court

No decisions concerning PSR were handed down in July/August 2022

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

One matter was referred to the major non-compliance (fraud) division in July/August 2022.

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in July/August 2022.