PSR Director's update for March 2025

Published date

A. Director or Associate Director’s section 92 agreements effective in March 2025

Six agreements entered into by the Director or an Associate Director and persons under review (in accordance with section 92 of the Act) came into effect in March 2025:

An agreement with an obstetrician/gynaecologist. 

During the review period, the practitioner rendered MBS item 16590 (planning and management of a pregnancy) in excess of 99% of their peers.

The Director reviewed this practitioner’s rendering of MBS item 16590 and had persisting concerns that:

  • services billed under the practitioner’s provider number were not always personally provided by them
  • for each service there was no record of the practitioner attending on the patient and no record the practitioner intended to be present at the time of birth
  • some reviewed services did not contain a mental health assessment as required
  • for some reviewed services, elements of MBS item 16590 were done during consultations where other professional attendance items were billed.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS item 16590. The practitioner agreed to repay $120,000, to be disqualified from providing MBS item 16590 services for 3 months, and will be counselled by the Director.

An agreement with a radiation oncologist. 

During the review period, the practitioner rendered some radiation oncology MBS items in excess of 99% of their peers.

The Director reviewed this practitioner’s rendering of radiation oncology MBS items. The Director had no concerns in relation to most MBS items reviewed. In relation to MBS item 91833 (specialist subsequent phone attendance), the Director had persisting concerns that the practitioner’s record keeping was inadequate and the MBS requirements were not always met.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 91833. The practitioner agreed to repay $16,000 and will be counselled by the Director.

An agreement with a general practitioner. 

During the review period, the practitioner rendered the following items in excess of 99% of their peers:

  • 5020 (after-hours attendance – less than 20 minutes)
  • 5028 (after-hours attendance at a residential aged care facility (RACF) – less than 20 minutes)
  • 5049 (after-hours attendance at a RACF – at least 20 minutes)
  • 16500 (antenatal attendance)
  • 90043 (attendance at a RACF – at least 20 minutes)
  • 30064 (removal of subcutaneous foreign body).

 The Director reviewed this practitioner’s rendering of MBS items:

  • 23 (attendance – less than 20 minutes)
  • 36 (attendance – at least 20 minutes)
  • 721 (preparation of a GP management plan (GPMP))
  • 723 (development of team care arrangements (TCAs))
  • 732 (review of a GPMP or TCAs)
  • 5049
  • 30064, and
  • 91891 (phone attendance – at least 6 minutes). 

The Director had persisting concerns that:

  • the MBS requirements were not always met, including minimum time requirements where relevant 
  • the practitioner did not always provide sufficient clinical input
  • the practitioner’s chronic disease management (CDM) services were not always clinically indicated
  • the practitioner’s record keeping was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS items 23, 36, 721, 723, 732, 5049, 30064 and 91891. The practitioner agreed to repay $248,000, to be disqualified from providing MBS item 36, 721, 30064, 91801 (video attendance – at least 20 minutes), 91900 (phone attendance – at least 20 minutes) and 92024 (video attendance to a prepare a GPMP) services for 12 months, and will be reprimanded by the Director. 

An agreement with a medical practitioner. 

During the review period, the practitioner rendered the following MBS items in excess of 99% of their peers:

  • 91891
  • 92210 (after-hours video attendance by a general practitioner for a condition requiring urgent assessment)
  • 92211 (after-hours video attendance by a medical practitioner for a condition requiring urgent assessment).

The Associate Director reviewed this practitioner’s rendering of MBS items 91891, 92210 and 92211, and had no concerns in relation to MBS item 91891. 

In relation to the remaining items, the Associate Director had persisting concerns that:

  • the MBS requirements were not always met, including that an urgent assessment was not always required
  • the practitioner’s record keeping was inadequate, including due to their use of templates that were not adequately tailored for the service
  • the practitioner’s clinical input and management of patient’s health issues was not always adequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 92210 and 92211. The practitioner agreed to repay $410,000. 

An agreement with a general practitioner. 

During the review period, the practitioner rendered MBS items 23 and 91800 (video attendance – less than 20 minutes), in excess of 99% of their peers. 

The Associate Director reviewed this practitioner’s rendering of MBS items 23, 36, 715 (health assessment for an Aboriginal or Torres Strait Islander patient), 721, 723, 732 and 91800, and had persisting concerns that:

  • MBS requirements, including minimum time requirements, were not always met
  • not all services were clinically indicated
  • the practitioner’s record keeping was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 715, 721, 723, 732 and 91800. The practitioner agreed to:

  • repay $335,000, 
  • be disqualified from providing MBS item 715, 723, 732, 91800, 91891, 92004 (video attendance for a health assessment), 92024, 92025 (video attendance to develop TCAs) and 92028 (video attendance to review a GPMP or TCAs) services for 24 months, 
  • be disqualified from providing MBS item 721 services for 12 months, 

and will be reprimanded and counselled by the Associate Director.

An agreement with a general practitioner. 

During the review period, the practitioner rendered the following MBS items in excess of 99% of their peers:

  • 44 (attendance – at least 40 minutes)
  • 2712 (review of a GP mental health treatment plan)
  • 5060 (after-hours attendance – at least 40 minutes)
  • 91802 (video attendance – at least 40 minutes).

The Associate Director reviewed this practitioner’s rendering of MBS items 44, 723, 2712 and 91802, and had no concerns in relation to MBS items 44, 2712 and 91802. In relation to MBS item 723, the Associate Director had persisting concerns that the MBS requirements were not always met and the plans were not always sufficiently comprehensive.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 723 and agreed to repay $10,000. 

B. No further action decisions

Request to review an ophthalmologist

During the review period, the practitioner rendered some MBS items in excess of 99% their peers, including:

  • 11221(full quantitative computerised perimetry)
  • 42738 (paracentesis of anterior chamber or vitreous cavity, or both)
  • 42788 (laser capsulotomy).

The Director reviewed a random sample of services rendered as MBS items 11221, 42738 and 42788. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

C. PSR Committee final determinations

PSR Committee 1280

On 25 March 2025 a final determination came into effect regarding a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS items 23, 36, 721, 723, 732 and 2713 (attendance in relation to a mental disorder of at least 20 minutes) services during the review period.

The practitioner was directed to:

  • be reprimanded 
  • be counselled 
  • repay the amount of $140,000. This reflects approximately the total benefits paid for the MBS item 23, 36, 721, 723, 732 and 2713 services in connection with which they were found to have engaged in inappropriate practice, and
  • be disqualified from rendering:
  • MBS item 721, 723, 92024 and 92025 services for a period of 12 months, and
  • MBS item 732 and 92028 services for a period of 6 months,

In relation to the MBS item 23 and MBS item 36 services the Committee made findings based on one or more of the following: 

  • The practitioner’s clinical input into the service was insufficient or inadequate
  • The medical record was inadequate
  • In relation to MBS item 36, the minimum time requirements were not met.

The Committee’s findings for the MBS item 721, 723 and 732 services (referred to as chronic disease management or CDM services) were for one or more of the following reasons: 

  • The patient did not attend on the date of service. The practitioner billed a standard attendance item when the patient did attend and would bill a CDM service shortly after, in order to avoid the prohibition on billing certain attendance items on the same day as CDM services
  • The GP Management Plan (GPMP) was not a comprehensive plan and often contained inaccurate information
  • There was no two-way communication with at least two other healthcare providers as required for a Team Care Arrangement (TCA) and the TCA often referred to practitioners who were not involved in the patients care
  • The GPMP and TCA review documents were not individualised to the patient
  • The medical record was inadequate

In relation to the MBS item 2713 services the Committee made findings based on one or more of the following: 

  • The patient did not have a recognised mental health disorder as required under the MBS, or was not treated for a mental disorder on the date of service
  • The minimum time requirements were not met
  • The service was not clinically indicated
  • The clinical input into the service was inadequate
  • The medical record was inadequate. 

PSR Committee 1490

On 20 March 2025 a final determination came into effect regarding a dentist. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with Child Dental Benefits Schedule (CDBS) items 88011 (comprehensive oral exam), 88114 (removal of calculus on first visit), 88161 (fissure and or tooth sealing per tooth – first 3 services on a day) and 88162 (fissure and or tooth sealing – subsequent services) services during the review period.

The practitioner was directed to:

  • be reprimanded 
  • be counselled 
  • repay the amount of $700,000. This reflects approximately the total benefits paid for the MBS item 88011, 88114, 88161 and 88162 services in connection with which they were found to have engaged in inappropriate practice, and
  • be disqualified from rendering CDBS items 88011, 88114, 88161 and 88162 services for a period of 12 months,

In relation to all of the CDBS items reviewed the Committee made findings based on the fact that the CDBS requirements were not met as the practitioner did not provide adequate supervision or oversight of the services performed to ensure that services were clinically necessary and performed to a satisfactory standard.

In addition, in relation to the CDBS item 88011 services the Committee made findings based on one or more of the following: 

  • The consent obtained from the patients’ parents was inappropriate as it did not correctly describe the services to be performed
  • The medical record was inadequate including that it did not reflect a comprehensive oral examination 
  • The medical record was inaccurate in reflecting that the practitioner performed the service when they were not present or a different service was documented to the service that was billed.

In relation to the CDBS item 88114 services the Committee made findings based on one or more of the following: 

  • The CDBS requirements were not met including that removal of calculus did not take place on the date of service
  • The service was not clinically indicated
  • The clinical record was inadequate and relied on an ambiguous and unreliable template to obtain consent
  • The record was inaccurate in reflecting the practitioner performed the service when they were not present.

In relation to the CDBS item 88161 and 88162 services the Committee made findings based on one or more of the following: 

  • The CDBS requirements were not met including that fissure seals were not performed on the date of service
  • The service was not clinically indicated
  • The clinical record was inadequate and relied on an ambiguous and unreliable template to obtain consent and it did not reflect the clinical reasoning for the fissure sealing
  • The record was inaccurate in reflecting the practitioner performed the service when they were not present and/or the person who did perform the service was named incorrectly.

PSR Committee 1543

On 25 March 2025 a final determination came into effect regarding an ophthalmologist. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS items 111 (subsequent specialist attendance where unscheduled operation is identified), 11240 (unilateral biometry), 42738 (paracentesis) and 42809 (photocoagulation laser of the retina) services during the review period.

The practitioner was directed to:

  • be reprimanded 
  • be counselled 
  • repay the amount of $265,000. This reflects approximately the total benefits paid for the MBS item 111, 11240, 42738 and 42809 services in connection with which they were found to have engaged in inappropriate practice, and
  • be disqualified from rendering MBS item 111services for a period of 12 months.

In relation to the MBS item 111 services the Committee made findings based on one or more of the following:

  • The MBS requirements were not met including that the operation was not urgent or unexpected or unable to be prescribed prior to the date of service and/or there was no separate consultation performed
  • The clinical input into the service was inadequate
  • The medical record was inadequate 

In relation to the MBS item 11240 services the Committee made findings based on one or more of the following:

  • The MBS requirements were not met as:
    • Bilateral rather than unilateral biometry was performed in anticipation of scheduled bilateral cataract surgery 
    • Biometry was to performed in anticipation of lens surgery
    • The practitioner had previously rendered an MBS item 11240 service for the same patient
  • The medical record is inadequate including by being contrived to justify sequential billing of unilateral biometry to maximise the Medicare benefits received

In relation to the MBS item 42738 services the Committee made findings based on one or more of the following:

  • The service was not clinically indicated and/or there was insufficient clinical indication for the treatment provided on the date of service
  • The clinical input into the service was inadequate
  • The medical record was inadequate.

In relation to the MBS item 42809 services the Committee made findings based on one or more of the following:

  • The service was not clinically indicated
  • The medical record was inadequate.

D. Federal Court

No federal court decisions we handed down in March 2025.

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

No matters were referred to the major non-compliance (fraud) division in March 2025.

F. Referrals to AHPRA (106XA/B)

2 matters were referred to AHPRA in March 2025.

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