PSR Director's update for November 2022

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

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

An agreement with an Other Medical Practitioner (OMP).

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 721, 723, 732, 45201 and 31358 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 703, 705, 707, 721, 723, 732, 900, 2712, 2713, 2717, 31363, 31364, 31365, 31366, 31367, 31368, 31369, 31370, 31376 and 45201. The Director had persisting concerns that:

• MBS requirements were not always met, including minimum time requirements where relevant, there was not always a clinical indication for health assessment services and patients did not meet eligibility criteria for a health assessment
• Chronic Disease Management (CDM) service documents did not reflect that an assessment of the patient was performed in order to determine their health care needs
• the practitioner’s record keeping was inadequate and would not enable another practitioner to effectively assume patient care

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 703, 705, 707, 721, 723, 732, 900, 2712, 2713, 2717, 31363, 31364, 31366, 31367, 31368, 31369, 31370, 31376 and 45201. The practitioner agreed to repay $740,000, to be disqualified from providing MBS item 45201 services for 36 months, to be disqualified from providing MBS item 703, 705, 707, 900, 2712, 2717, 92114, 92117 and 92126 services for 12 months, and will be reprimanded by the Director.

An agreement with a Nurse Practitioner.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) item 82215 in excess of 99% of their peers, and prescribed Pharmaceutical Benefits Scheme (PBS) item 11147Q disproportionately to their peers. The Director reviewed this practitioner’s rendering of MBS item 82215 and PBS item 11147Q. The Director had persisting concerns that:

• MBS requirements were not always met. For example, many of the records do not reflect consultations of at least 40 minutes, with many records showing routine appointments
• the practitioner’s record keeping was inadequate.  For example, there is no documentation reflecting that PBS requirements were met for 11147Q or that the medicine was clinically indicated for particular patients

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Item 82215 and prescribing PBS Item 11147Q. The practitioner agreed to repay $65,000, to be disqualified from providing MBS item 82215 services for 6 months, and will be reprimanded by the Director.

An agreement with a Nurse Practitioner.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 82215 and 91180 in excess of 98% of their peers, and prescribed Pharmaceutical Benefits Scheme (PBS) item 11147Q disproportionately to  peers. The Director reviewed this practitioner’s rendering of MBS items 82215 and 91180, and PBS item 11147Q, The Director had persisting concerns that:

• MBS requirements were not always met.  For example, many of the records do not reflect consultations of at least 40 minutes, with many records showing routine appointments
• the practitioner’s record keeping was inadequate.  For a number of the reviewed MBS item 91180 services, the records did not reflect any history, examinations or management plans
• the PBS requirements were not always met, including as to evidence of chronic hepatitis C infection, or the presence or absence of cirrhosis

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 82215 and 91180, and prescribing PBS Item 11147Q.  The practitioner agreed to repay $54,000, to be disqualified from providing MBS item 82215 and 91180 services for 6 months, and will be reprimanded by the Director.

An agreement with a General Practitioner.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 45201 and 45202 in excess of 99% of their peers, and prescribed Pharmaceutical Benefits Scheme (PBS) ATC group items in variance to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 30071, 45201, 45202 and 91809, and PBS items 1165H, 1215Y, 2622B, 3162K, 8501K, 8502L and 8785J, and had no concerns in relation to MBS items 30071. In relation to the remaining items, the Director had persisting concerns that:

• MBS requirements were not always met, including minimum time requirements where relevant
• the practitioner’s record keeping was inadequate.  For example, the records show repetitive copying and pasting of notes from prior consultations, making the records confusing and unclear
• the rendering of skin procedural items was not always clinically indicated
• the practitioner’s management of the patients to whom PBS items were prescribed was not always appropriate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 45201, 45202 and 91809, and prescribing PBS Items 1165H, 1215Y, 2622B, 3162K, 8501K, 8502L and 8785J. The practitioner agreed to repay $120,000, to be disqualified from providing MBS item 45202 services for 3 months, and will be reprimanded by the Director.

An agreement with a Psychiatrist.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 296, 348, 352, 92498 and 92500 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 296, 348, 352, 92498 and 92500, and had no concerns in relation to MBS items 296. In relation to the remaining items, the Director had persisting concerns that:

• the practitioner’s record keeping was inadequate, including in respect of some services  where there were no notes kept relevant to the services billed
• MBS requirements were not always met, including minimum time requirements where relevant
• the practitioner did not always provide sufficient clinical input, particularly in managing patients with attention deficit hyperactivity disorder

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 348, 352, 92498 and 92500. The practitioner agreed to repay $61,000, to be disqualified from providing MBS item 92458 services for 6 months, and will be reprimanded by the Director.

An agreement with a General Practitioner.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 36, 44, 705, 721, 723 and 41647 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 721, 723, 732, 31358, 31363, 41647, 45201, 45202, 91810 and 91811. The Director had persisting concerns that:

• MBS requirements were not always met. For example, CDM plans were not always comprehensive plans for managing patient’s chronic diseases
• the practitioner’s record keeping was inadequate.  For example, the records were often brief and did not contain relevant patient history, examinations findings, or management
• not all MBS item 45202 services were clinically indicated

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 721 and 45202. The practitioner agreed to repay $37,000, and will be reprimanded by the Director.

B. PSR Committee final determinations

PSRC 1059

On 15 November 2022 a final determination came into effect regarding a radiologist.  The radiologist was directed to:

• be reprimanded
• be counselled
• repay the amount of $330,000 to the Commonwealth, which represented approximately 50% of the benefit paid in respect of items 104 and 105 in the review period. This reduction took into account not only certain mitigating factors, but also sought to reflect the impact of the multiple services rules in reducing the benefit paid for diagnostic imaging services that were rendered in association with these attendance items.
• be disqualified from rendering MBS item 104 and 105 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 MBS items 104, 105, 18216 and 18222.

In relation to the attendance services (MBS items 104 and 105) the Committee made findings on the basis of one or more of the following:

• MBS requirements were not met, including that the elements said to make up MBS item 104 or 105 services were billed separately under a different MBS item number, and the service required the practitioner’s professional attendance during the performance of the scan.
• There was insufficient clinical input to justify rendering an MBS item 104 or 105 service, such that it was not a clinically relevant service.
• There was no consultation on the date of service.
• There was no valid referral for the service.
• The practitioner’s clinical input into the service was inappropriate.
• Co-billing of other MBS item numbers was not appropriate in the circumstances. In this regard, the Committee considered that there was an inadequate system in place to ensure appropriate billing.
• The medical record was inadequate, including that there was no record of any meaningful consultation.

In relation to the MBS item 18216 services (intrathecal or epidural infusion of a therapeutic substance, initial injection or commencement of, including up to 1 hour of continuous attendance by the medical practitioner) the Committee made findings on the basis of one or more of the following:

• MBS requirements were not met, including that
  • the service involved an injection, not an infusion as required,
  • the injection was into the wrong location, and/or
  • there was no valid referral in the record.
• The clinical input into the service was not appropriate in that the service was not clinically necessary.

In relation to the MBS item 18222 services (infusion of a therapeutic substance to maintain regional anaesthesia or analgesia, subsequent injection or revision of, where the period of continuous medical practitioner attendance is 15 minutes or less) the Committee made findings on the basis of one or more of the following:

• MBS requirements were not met, including:
  • Inappropriately co-billing other MBS item numbers,
  • Carrying out injections rather than infusions as required, and/or
  • Initiating, rather than maintaining, anaesthesia or analgesia.

PSRC 1463

On 21 November 2022 a final determination came into effect regarding a medical practitioner.  The medical practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $200,000 to the Commonwealth
• be fully disqualified from rendering MBS item services for a period of 6 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 provided as MBS items 23, 721, 723, 732, 2715 and PBS items 1215Y (paracetamol 500mg + codeine 30mg table) and 3162K (diazepam 5mg tablet).

In relation to the attendance services (MBS item 23) the Committee made findings on the basis of one or more of the following:

• MBS requirements were not met, including that no, or no adequate, patient history and examination were recorded
• the clinical input into the service was inadequate as there was no appropriate management plan implemented
• the medical record was inadequate.

In relation to the chronic disease management services (MBS items 721, 723 and 732) the Committee made findings on the basis of one or more of the following:

• there was insufficient clinical input into the development of GP Management Plans (GPMP), the development of Team Care Arrangements (TCAs) and the review of existing GPMPs and TCAs, as these services were provided almost entirely by a practice nurse
• MBS requirements were not met including:
  • the GPMPs were not a comprehensive written plan and/or were not sufficiently individualised for the patient
  • the TCAs did not involve collaboration with at least two other healthcare providers and/or were not sufficiently individualised for the patient
• the medical record was inadequate including by being overly reliant on templates.

In relation to Level C consultations for mental health treatment plans (MBS item 2715) the Committee made findings including on the basis that the medical record was inadequate and the MBS requirements were not met as the mental health treatment plan was a standard template that was not individualised for the patient and failed to record key clinical information.

In relation to the prescribing of PBS items 1215Y and 3162K the Committee made findings on the basis that the clinical management of patients prescribed Panadeine Forte or diazepam was inadequate and/or the medical records were inadequate.

C. Federal Court

No decisions concerning PSR were handed down in November 2022

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

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

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in November 2022.