PSR Director's Update for June 2022

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

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

An agreement with a Neurologist.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 110, 11018 and 11021 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 110, 11018 and 11021. The Director had persisting concerns that:

• the practitioner did not always perform a separate consultation when billing MBS item 110, nor was a separate consultation always referred or clinically indicated
• to the extent a separate MBS item 110 service was provided, the practitioner’s records were inadequate

• there was not always a clinical indication for a nerve conduction study involving four separate nerves
• the practitioner’s clinical input was inadequate in nerve conduction studies where additional testing appeared to be indicated but did not occur and in qEMG tests where there was insufficient muscle sampling, and
• qEMG tests were performed without clinical indication and instead of a standard EMG.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 110, 11018 and 11021. The practitioner agreed repay $170,000 and will be reprimanded by the Director.

An agreement with a General Practitioner.

During the review period, the practitioner rendered a high volume of both total and daily services compared to peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 5020, 5023 and 5040. The Director had no concerns about MBS item 5023. Regarding the remaining items, the Director had persisting concerns that:

• the practitioner’s records were not always adequate. For example, the records were often very brief and lacked important clinical information
• the MBS item descriptors were not always met, including the minimum time requirements where relevant
• the practitioner did not always provide adequate clinical input

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 5020 and 5040. The practitioner agreed to repay $170,000 and will be reprimanded by the Director.

An agreement with a General Practitioner.

During the review period, the practitioner rendered a high volume of both total and daily services and rendered MBS items 721 and 723 in excess of 97% and 98%, respectively, of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 5028 and 90035. The Director had no persisting concerns about MBS item 5028. Regarding the remaining items the Director had persisting concerns that:

• the MBS item descriptors were not always met. For example, there was a lack of evidence to indicate there was two-way communication with other practitioners in relation to Team Care Arrangements
• the practitioner’s records were not always adequate as they were often brief and failed to record important clinical information and they would not allow another practitioner to effectively assume the patient’s ongoing care in reliance on the record, and
• the practitioner’s clinical input in relation to MBS items 23 and 90035 services was not always adequate for the level of complexity required for a Level B service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 721, 723 and 90035. The practitioner agreed to repay $220,000, be disqualified from providing MBS items 721, 723, 92024, 92025, 92068 and 92069 services for a period of 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92024, 92025, 92068 and 92069 reflects disqualification from equivalent telehealth items where applicable.

B. PSR Committee final determinations

Two final determinations came into effect in June 2022

PSRC 1172

On 22 June 2022 a final determination came into effect regarding a dental practitioner. The practitioner was directed to:

• be reprimanded
• be counselled
• repay $650,081.60, less the amount of $2865.10 previously repaid, to the Commonwealth and
• be disqualified from rendering Child Dental Benefit Scheme (CDBS) item 88011, 88022, 88114, 88121, 88161, 88531 and 88532 services for a period of 12 months

These directions followed from a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with services rendered as CDBS items 88011, 88022, 88114, 88121, 88161, 88531 and 88532.

The dental practitioner did not personally attend on patients to render any of the services examined by the Committee, as the patients were attended by oral health therapists who billed services under the dental practitioner’s provider number. In these circumstances the Committee considered the practitioner’s conduct in connection with the services to involve conduct unacceptable to their peers because:

• the practitioner assumed responsibility for a level of supervision that was greater than what was actually performed
• the practitioner failed in their role as the clinical team lead to oversee the relevant system of work
• there was no Structured Professional Relationship in place with any of the practitioners who rendered services on the dental practitioner’s behalf, as was required.

And as a result of the conduct of the dental practitioner one or all of the following issues presented themselves in relation to services provided under their provider number as CDBS items 88011, 88022, 88114, 88121, 88161, 88531 and 88532:

• the consent practices were inadequate, including inadequate documentation of informed consent both for the treatment itself and the financial impost likely to be involved
• the records were deficient in other essential clinical information including the patient history and examination findings, and were often inaccurate and unreliable due to the use of ‘quicknotes’
• the radiographs reviewed were of inadequate quality
• there was a failure to comply with CDBS billing requirements
• treatments were provided that were not clinically indicated and investigations that were indicated, such as two bite-wing radiographs, were not performed
• the treatment planning was inappropriate or inadequate
• in relation to CDBS item 88022, some children were exposed to radiation without clinical benefit
• in relation to CDBS item 88121 there was inappropriate application of remineralisation and/or cariostatic agent to the patient based on their age, the agent was not applied in accordance with relevant instructions, and there was inappropriate application of 1.23% fluoride foam given the patient’s age
• in relation to CDBS item 88161, the material used and the preparation with phosphoric acid were not suitable for fissure sealing
• in relation to CDBS items 88531 and 88532, an excessive number of services were performed on the date of service, having regard to the patient’s age and/or presentation and the use of anaesthetic was clinically indicated but not administered.

PSRC 1283

On 22 June 2022 a final determination came into effect regarding a medical practitioner. The practitioner was directed to:

• be reprimanded
• be counselled and
• repay $187,622.53 to the Commonwealth

These directions followed from a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with services provided as MBS items 36, 597, 599 and PBS items 3119E and 8245K.

In relation to MBS items 36, the Committee made findings of inappropriate practice on the basis of one or more of the following:

• the clinical input was inadequate
• the MBS requirements, including the minimum time requirements for the item, were not met
• the medical records were inadequate.

In relation to MBS items 597 and 599 the Committee made findings of inappropriate practice on the basis of one or more of the following:

• the MBS requirements, in particular the requirement that the service be ‘urgent’ were not complied with
• the clinical input was inadequate
• the medical records were inadequate.

In relation to PBS item 3119E (cefalexin) the Committee made findings of inappropriate practice on the basis of one or more of the following:

• the clinical input was inadequate
• the prescriptions were not always clinically indicated.

In relation to PBS items 8254K (amoxycillin and clavulanic Acid), the Committee made findings of inappropriate practice on the basis that the clinical input into the service was inadequate. 

C. Federal Court

No decisions concerning PSR were handed down in June 2022.

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

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

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in June 2022.