PSR Director's Update for March 2021

Published date

A. Director’s Section 92 agreements effective in March 2021

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 haematologist.

During the review period, the practitioner was the highest ranked renderer of Medicare Benefit Schedule (MBS) items 132 and 133 among haematologists nationally. The Director reviewed this practitioner’s rendering of MBS items 132, 133, 13703 and 13706. The Director had persisting concerns that:

  • there was not always a clinical indication when rendering MBS item 132 and 133 services. For example, not all of these services were provided to patients who had at least two morbidities that warranted a treatment and management plan of significant complexity
  • the reviewed records did not always reflect that the MBS requirements were met, including minimum time requirements where relevant. For example, the reviewed records indicate that MBS items 13703 and 13706 were billed when the practitioner provided iron infusions, rather than transfusions of blood or blood products
  • the practitioner’s records did not always reflect that the practitioner provided sufficient clinical input and
  • the records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $330,000, to be disqualified from providing MBS items 132, 133, 13703 and 13706 for 12 months, 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 30196 than 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23 and 30196. The Director had persisting concerns that:

  • MBS item 30196 services were provided in circumstances where there did not appear to be a clinical indication
  • the MBS requirements for MBS item 23 were not always met
  • the practitioner’s clinical input was not always sufficient for each service
  • the practitioner may not have removed a malignant lesion, as required by the MBS item 30196 descriptor and
  • the records were inadequate.

The practitioner acknowledged having 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 item 30196 for 24 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered a volume of total services in excess of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 701, 707, 721, 723, 2525, 55065, 55116, 56223 and 58112 and initiation of MBS items 66596 and 66839 and had persisting concerns relating to items 23, 36, 701, 721, 723, 58112 66596 and 66839 that:

  • the MBS requirements were not always met. For example, the practitioner’s General Practitioner Management Plan (GPMP) and Team Care Arrangements, for MBS items 721 and 723, appeared to be inadequate and not sufficiently individualised to the patients
  • the practitioner’s clinical input was inadequate
  • the records were inadequate and
  • not all services were clinically indicated, including iron studies and Vitamin B12 markers that were initiated for screening purposes.

The practitioner acknowledged having 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 721 and 723 for 12 months, and will be reprimanded by the Director.

An agreement with an urologist.

During the review period, the practitioner rendered total and daily services in excess of a majority of their peers, including providing a high volume of MBS item 37008 services. The Director reviewed this practitioner’s rendering of MBS items 105, 37008, 37201, 37218 and 37219, and aside from item 105, had persisting concerns that:

  • the MBS requirements were not always met, for example MBS item 37008 was billed where a suprapubic catheter was inserted via a stab cystotomy rather than a cystostomy or cystotomy by transabdominal approach
  • where other MBS items were co-billed with MBS item 37008, it was not always clear that the MBS item requirements for each service were met
  • the practitioner did not adequately take patient consent. For example, the practitioner did not always appropriately articulate the procedure being performed and the consent forms were not sufficiently individualised and did not reflect that the patient had been advised of alternative treatment options and
  • MBS items 37218 and 37219 were co-billed where the performance of both a finger biopsy and an ultrasound biopsy may not have been clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $75,000, to be disqualified from providing MBS items 37008 and 37218 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner.

During the review period, the practitioner rendered MBS item 54 in excess of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS item 54, initiating of MBS items 65075, 66707, 66752, 71099 and 71166, and rendering of Pharmaceutical Benefits Schedule (PBS) items 3162K and 8254K. The Director had persisting concerns that:

  • the practitioner’s records were inadequate and for some services, a record could not be located
  • the MBS requirements, including minimum time requirements where relevant, were not always met
  • not all services and prescribing of medications appeared to be clinically indicated
  • the practitioner had billed the item for the provision of cosmetic services, which are not rebatable under Medicare
  • in some of the reviewed services, the practitioner appeared to initiate pathology services for screening purposes and
  • the practitioner did not appear to always meet the PBS restrictions when prescribing PBS item 8254K.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $65,000, to be disqualified from providing or initiating MBS items 54, 65075, 66752, 71166 and 71099 for 12 months, and has been reprimanded by the Director.

An agreement with a dentist.

During the review period, the practitioner rendered Child Dental Benefits Schedule (CDBS) items 88011, 88111, 88121 and 88161 in excess of the majority of their peers, being other dentists active under the CDBS in Australia. The Director reviewed this practitioner’s rendering of CDBS items 88011, 88111, 88121 and 88161 and aside from  88011, had persisting concerns that:

  • not all services were clinically indicated. For example, the practitioner rendered CDBS item 88111 services in respect of patients as young as 27 or 30 months old where there was no documented prevalence of stains or plaque recorded and
  • the practitioner’s records were inadequate. For example, the records did not always include sufficient information to document procedures, such as the technique used in sealing fissures.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $200,000, to be disqualified from providing CDBS item 88161 for six months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered or initiated more services as MBS items 721, 732, 63551, 63560, 66596, 66716, and 66838 than 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721 and 732, initiating of MBS items 55036, 55065, 58503, 63551, 63560, 66596, 66716 and 66838 and rendering of PBS items 3119E and 8254K. The Director had persisting concerns that:

  • the records were inadequate. In respect of MBS item 23, the notes did not always contain sufficient clinical information, such as an appropriate examination or history, to explain what occurred during the consultation
  • the practitioner did not always provide adequate clinical input. For example, in the reviewed records for diagnostic imaging services, these services appeared to be initiated without undertaking relevant examinations or obtaining a sufficient patient history
  • the services did not always meet the MBS item requirements
  • there was not always a clinical indication for the practitioner’s initiating of pathology and diagnostic services or prescribing of antibiotics and
  • the practitioner did not appear to always meet the PBS restrictions when prescribing PBS item 8254K.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $290,000, to be disqualified from providing MBS items 721 and 732 for 12 months, 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 and 732 than 98 per cent of all active general practitioners in Australia. The Director reviewed this practitioner’s rendering of MBS items 23, 707, 721, 723, 732, 10997, 11610 and 11700 and PBS items 2622B and 8254K. The Director had persisting concerns that:

  • the MBS requirements, including minimum time requirements where relevant, were not always met. For example, for MBS item 707, in some instances it did not appear that the practitioner personally attended upon the patient to conduct an extensive examination, initiate interventions or referrals or provide a comprehensive preventative healthcare management plan
  • there was not always a documented clinical indication for each service
  • the records were inadequate
  • the practitioner did not always provide sufficient clinical input and
  • the practitioner prescribed PBS items 2622B and 8254K outside of the PBS restrictions and without clinical indication.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $320,000, to be disqualified from providing MBS items 707, 732, 723 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered or initiated more services as MBS items 44, 707, 66822, 66728 and 66734 than of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 44, 707, 721, 723 and initiation of MBS items 66728, 66734 and 66822. The Director had persisting concerns that:

  • the practitioner’s billing of MBS item 44 was not consistent with MBS requirements. The records were brief and did not contain sufficient information to suggest that an extensive patient history was taken or that a necessary examination was performed, and the minimum time requirements did not always appear to be met
  • the  clinical notes were inadequate
  • the MBS item requirements (including minimum time requirements and eligibility requirements where relevant) were not always met and
  • there was not always a clinical indication for the initiation of pathology services.

The practitioner acknowledged having 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 items 707, 721 and 723 for 12 months, 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 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36 and 41647 and had persisting concerns that for items 36 and 41647:

  • the records were inadequate
  • the MBS requirements were not always met. In respect of MBS item 41647, the services may not have required the use of an operating microscope for microinspection of the tympanic membrane and
  • not all services were clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $75,000, to be disqualified from providing MBS item 41647 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner’s volume of daily servicing on many days was in excess of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721 and 723 and had persisting concerns that:

  • the records were inadequate
  • the MBS item requirements, including minimum time requirements where relevant, were not always met and
  • the practitioner did not always provide sufficient clinical input. For example, in several of the reviewed GPMPs, where patients appeared to have a number of chronic conditions, the plans only focused on managing a single condition.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $100,000, to be disqualified from providing MBS items 721 and 723 for 12 months, 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 732 than 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723 and 732. The Director had persisting concerns that:

  • the MBS requirements for chronic disease management items were not always met. In none of the reviewed records for the practitioner’s 721 services was there evidence of collaboration with the other team members prior to preparing the team care arrangement document
  • the records were inadequate and
  • the practitioner did not provide sufficient clinical input into services.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $135,000, to be disqualified from providing MBS items 721, 723 and 732 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

One final determination came into effect in March 2021. The details of this matter will be published in an upcoming case outcome publication.

C. Federal Court

No decisions concerning PSR were handed down in March 2021.

D. Referrals to the major non-compliance (fraud) division (s89A & s106N)

No matters were referred to the major non-compliance (fraud) division in March 2021.

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in March 2021.

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