PSR Director's update for June 2024

Published date

A. Director’s Section 92 agreements effective in June 2024

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

An agreement with a medical practitioner 

During the review period, the practitioner rendered MBS items 36, 44 and 5049 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 705, 2713, 91891, 92115 and 92746. The Director had persisting concerns that

  • the practitioner’s record keeping was inadequate, including where their notes contained insufficient information to explain what occurred during attendances
  • MBS requirements were not always met, including where the practitioner did not always personally provide attendances, and observe minimum time requirements where relevant

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 705, 2713, 91891, 92115 and 92746. The practitioner agreed to repay $570,000, to be disqualified from providing MBS item 705, 91891, 92115 and 92746 services for 12 months, to be disqualified from providing MBS item 36, 44, 91801 and 91802 services for 10 months, and will be reprimanded by the Director. 

An agreement with a medical practitioner 

During the review period, the practitioner rendered several MBS imaging items in excess of 99 % of their peers. The Director reviewed this practitioner’s rendering of 3 MBS imaging items and had no concerns in relation to 1 item. The Director had persisting concerns in relation to the remaining items that:

  • the practitioner’s record keeping was inadequate in that the clinical indication for providing 2 MBS imaging items services was not clear from the records  
  • the practitioner’s reports to referring practitioners were inadequate as they did not make clear reference to relevant MBS imaging services having been performed or include any analysis or reporting on anatomical regions covered by the two items

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering 2 MBS imaging items. The practitioner agreed to repay $900,000, to be disqualified from providing services under 2 specified MBS imaging items for 12 months, and will be reprimanded and counselled by the Director. 

B. PSR Committee final determinations

PSR Committee 1339

On 19 June 2024 a final determination came into effect regarding a general practitioner. The practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee in connection with MBS items 23, 36, 721, 723, 2717, 5020, 5040, 5043, 5049, 30026, 30032 and 30064 services during the review period.

The practitioner was directed to:

  • be reprimanded 
  • be counselled 
  • repay the amount of $610,000 to the Commonwealth in respect of MBS item 23, 36, 721, 723, 2717, 5020, 5040, 5043 and 5049 services in connection with which the practitioner was found to have engaged in inappropriate practice. 
  • The practitioner be disqualified from rendering:
    • MBS item 36 and 91801 services for 3 months,
    • MBS item  5028, 5040, 5043 and 5049 services for 6 months, and
    • MBS item 721, 723, 2717, 92024, 92025 and 92117 services for 12 months.

In relation to the MBS item 23 and 5020 services the Committee made findings based on one or more of the following: 

  • The practitioner’s clinical input and / or management of the patient was inadequate.
  • The MBS requirements were not met with respect to one or more of the following:
    • The practitioner failed to take an appropriate history, record his examination and / or diagnosis, and / or
    • There was no consultation note or corroborative evidence on the date of the service to indicate that the practitioner personally attended on the patient. Alternatively, if the practitioner did attend on the patient, he failed to make an adequate and contemporaneous record of the service, and / or
    • There was insufficient clinical input provided to support the MBS requirements for a Level B consultation. Alternatively, if there was some aspect of the consultation or input provided to justify the rendering of a Level B consultation, the record was inadequate in failing to record this.
    • For MBS item 5020, the attendance was not performed in the after-hours period and / or
  • The medical record is otherwise inadequate.

In relation to the MBS item 36 and 5040 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met in that:
    • the practitioner did not record a detailed history, and / or
    • there was insufficient clinical input to justify an attendance of at least 20 minutes. Alternatively, if there was some other complexity or aspect of the service that would have justified a consultation of at least 20 minutes, the record is inadequate for failing to document this, and / or
    • there was insufficient clinical input recorded to justify co-billing of an MBS item 36 service with another procedural item billed on the same date, and / or
    • the service was for a presentation covered by workers’ compensation and not eligible to be billed to Medicare, and / or
    • the consultation did not appear to be clinically indicated, in view of preceding services rendered, and / or
    • The patient record does not support that the practitioner personally attended the patient on the date of the service, and if he did so, the MBS requirements were not met and the medical record was inadequate.
  • The medical record was otherwise inadequate.
  • The practitioner’s clinical input into the service was inadequate.

In relation to the MBS item 721 services the Committee made findings based on one or more of the following: 

  • The MBS requirements for billing an MBS item 721 service were not met including in that:
    • the GPMP was derived from a basic template and not tailored to the patient’s healthcare needs in any way, and / or
    • the document did not contain a comprehensive management plan to address the patient’s needs.
  • The practitioner’s clinical input was inadequate, or inappropriate.
  • The plan would not be of use to the patient or any other health practitioner relying on it in improving the management of the patient.
  • The medical record was otherwise inadequate.

In relation to the MBS item 723 services the Committee made findings based on one or more of the following: 

  • The MBS requirements for billing an MBS item 723 service were not met, including in that:
    • No Team Care Arrangement service was performed, or
    • If a Team Care Arrangement service was performed, it was not recorded in any way.
  • The practitioner’s clinical input was inadequate.
  • The medical record was otherwise inadequate.

In relation to the MBS item 2717 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met in that there was insufficient clinical content to justify a consultation lasting at least 40 minutes. In the alternative, if there was some aspect of the consultation that would have justified a 40 minute consultation, the record is inadequate for failing to record this.
  • The practitioner’s clinical input was inadequate.
  • The medical record is otherwise inadequate.

In relation to the MBS items 5028, 5043 and 5049 services the Committee made findings based on one or more of the following: 

  • There was no, or insufficient, clinical indication for the service, and / or
  • The practitioner failed to take an adequate and /or contemporaneous record of the service, and / or
  • The medical record was otherwise inadequate. and/or
  • For most services rendered, there was no, or insufficient, evidence to confirm the practitioner attended the patient on the date of the service, and if he did the regulatory requirements for an MBS item 5028 or 5049 service were not met, 
  • Otherwise, the regulatory requirements were not met for: 
    • an MBS item 5028 service in that the practitioner did not take an adequate history, record his examination, diagnosis or assessment or any clinical tasks performed in order to justify billing the MBS item 5028 service,
    • an MBS item 5043 and 5049 services in that the presentation and / or the clinical content recorded does not justify an attendance of at least 20 minutes duration and which, for MBS item 5049 services, would otherwise meet the MBS requirements,

In relation to the MBS item 30026 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met in that:
    • there is no repair of wound recorded that would meet the requirements for an MBS item 30026 service, and / or
    • the practitioner repaired the wound with Steri-Strips only and not by suture, glue or clips, as required. If the practitioner did also apply glue in addition to the Steri-Strips, this was not recorded and the record is inadequate, and / or
    • the practitioner included the time spent treating the wound, and for which he separately billed a MBS consultation item, as part of his calculation of the time spent for the rendering of an associated consultation. 
  • The practitioner impermissibly billed for aftercare of a service rendered earlier.
  • There is insufficient evidence to corroborate a personal attendance by the practitioner on the patient on the date of the service. If the practitioner did attend the patient, he failed to make an adequate and contemporaneous record, and failed to meet the MBS requirements.
  • The medical record was otherwise inadequate.

In relation to the MBS item 30032 and 30064 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met for MBS item 30032 in that:
    • the repair of wound was not on the face or neck, as required by the descriptor, and / or
    • the wound was not otherwise repaired by the practitioner in accordance with the MBS requirements for billing an MBS item 30032 service.
  • The MBS requirements for billing an MBS item 30064 service were not met in that the practitioner:
    • did not remove a foreign body from subcutaneous tissue, and / or
    • the procedure did not require incision and exploration, including closure of a wound.
  • The practitioner included the time spent treating the wound, and for which he separately billed MBS item 30032 and MBS 30064, as part of his calculation of the time spent for an associated co-billed consultation. 
  • The medical record was inadequate. 

PSR Committee 1450

On 10 June 2024 a final determination came into effect regarding a general practitioner. The practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee in connection with providing MBS items 23, 5020, 58503, 57509 and 57521 services during the review period.

The practitioner was directed to:

  • be reprimanded
  • be counselled
  • repay the amount of $340,000 to the Commonwealth in respect of MBS services in connection with which the practitioner was found to have engaged in inappropriate practice.

In relation to the MBS item 23 and 5020 services the Committee made findings based on one or more of the following: 

  • The MBS requirements for MBS items 23 and 5020 services were not met, including that:
    • The medical record did not contain sufficient clinical information to explain the service the practitioner provided on the date of the service
    • the record did not disclose the level of input required for a Level B service. If additional clinical input was provided in relation to the services, the record was inadequate in failing to record this.
    • due to the deficiencies in the record, it would not be clear to another practitioner assuming care what had occurred in the consultation and why.
    • for one MBS item 23 services and two MBS item 5020 services, there was no record for the date of the service.
  • The practitioner’s clinical input into the service was insufficient, or inadequate.
  • The medical record was otherwise inadequate.

In relation to the MBS item 58503, 57509 and 57521 services the Committee made findings based on one or more of the following: 

  • The x-ray initiated was not clinically necessary. The records did not reflect a clinical indication for x-ray 
  • The medical record was inadequate 
  • The practitioner’s clinical input into the service was insufficient and / or inappropriate for MBS item 58503.

C. Federal Court

No final decisions concerning PSR were handed down in June 2024.

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

No matters were referred to the major non-compliance (fraud) division in June 2024.

E. Referrals to AHPRA (106XA/B)

5 matters were referred to AHPRA in June 2024.

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