PSR Director's Update for September 2022

Published date

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

One agreement entered into by the Director and a person under review (in accordance with s 92 of the Act) came into effect in September 2022:

An agreement with a General Practitioner.

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 31358, 31360, 31363, 31364, 31367, 31368, 31369, 31370 and 45201 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 31358, 31363, 31364, 31367, 31368, 31369, 31370 and 45201.  The Director also reviewed this practitioners prescribing of Pharmaceutical Benefits Scheme (PBS) item 8254K. The Director had persisting concerns that:

  • the services were not always clinically indicated
  • MBS requirements were not always met in relation to skin lesion size, site or malignancy
  • the records were inadequate.  For example, it is difficult to ascertain whether informed consent for the therapeutic procedures had been obtained
  • The practitioner did not always meet PBS requirements when prescribing PBS item 8254K.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 31358, 31363, 31364, 31367, 31368, 31369, 31370 and 45201 and PBS item 8254K. The practitioner agreed to repay $38,000 and will be reprimanded by the Director

B. PSR Committee final determinations

Three final determinations came into effect in September 2022:

PSRC 1093

On 12 September 2022 a final determination came into effect regarding a dermatologist. The final determination relates to the period of practice from 1 July 2015 to 30 June 2016. The practitioner was directed to:

  • be reprimanded
  • be counselled
  • repay $237,450.60 to the Commonwealth and
  • be fully disqualified from rendering MBS services for 12 months.

These directions followed a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with the rendering of MBS items 104, 105, 14109, 18234, 18362, 45026 and 45506.

In relation to the specialist attendance items, MBS item 104 and 105, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the MBS requirements were not met including in that:
    • there was no valid referral for the service
    • for item 104, the service was not an initial attendance in a single course of treatment and no initial consultation was performed
    • the only medical record for the date of service was for a co-billed procedural item and where there was no evidence of a consultation separate to the procedure having been performed
  • services were not clinically relevant and were performed for purely cosmetic reasons
  • clinical input was inadequate
  • the medical record was inadequate
  • there was no letter back to the referring practitioner where such a letter was indicated and/or specifically requested by the referring practitioner

In relation to MBS item 14109, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the MBS item requirements were not met in that the services related to treatments not permitted (or expressly excluded) by the descriptor, and the minimum size requirement for the treatment area was not satisfied 
  • the medical record was inadequate.

In relation to MBS item 18234 the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS item requirements were not met as the service did not involve an injection of anaesthetic to the primary division of the trigeminal nerve
  • the medical record was inadequate
  • there was no letter back to the referring practitioner where such a letter was indicated and/or specifically requested

In relation to MBS item 18362 the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the MBS requirements were not met as the patient did not meet the eligibility criteria for the service
  • If the patient did meet the MBS eligibility criteria for the service, the medical record was inadequate for failing to adequately document this
  • the medical record was otherwise inadequate, including as to how the procedure was performed and by whom, quantity of Botox prescribed and administered
  • there was no letter reporting back to the referring practitioner, where such a letter was indicated

In relation to MBS item 45026 the Committee made findings of inappropriate practice on the basis that:

  • the MBS requirements were not met in that:
    • fractional laser therapy was performed rather than, or in combination with, ablative laser treatment
    • any fully ablative laser performed was to focal areas within an aesthetic unit only, and not more than one entire aesthetic area
    • not all treatments were for severely disfiguring scarring
  • The medical record was otherwise inadequate in the documenting of level of scarring, the laser technique used and areas involved 

In relation to MBS item 45506 the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the item was billed for subcision and/or TCA-CROSS therapies performed over multiple visits as part of a course of treatment, with each instance involving partial scar revision only, rather than for a complete scar revision in a single service
  • the therapy performed at each service did not match the complexity of a surgical excision with closure expected for a complete scar revision service, and noting other MBS items available for simple scar revision procedures
  • the medical record was otherwise inadequate, in terms of identifying the type, size and location of scars treated, or method used to perform the treatment, and noting photographs alone did not provide the requisite detail expected for this type of procedure.  

PSRC 1294

On 12 September 2022 a final determination came into effect regarding a general practitioner. The practitioner was directed to:

  • be reprimanded
  • be counselled
  • repay the amount of $320,190.20 to the Commonwealth
  • be disqualified from rendering
    • MBS item 721 and 723 services for a period of 12 months and
    • MBS item 2717 services for a period of 24 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 36, 44, 721, 723, 2713 and 2717.

In relation to professional attendance items, MBS items 36 and 44, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the records were inadequate, including that there was no record for the date of service or there was insufficient clinical content recorded
  • MBS requirements were not always met including that there was not always sufficient clinical content to support a consultation of at least 20 minutes (MBS item 36) or 40 minutes (MBS item 44)
  • clinical input was not always adequate

In relation to the Chronic Disease Management (CDM) services (MBS items 721 and 723), the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the records were inadequate, including that in some of the reviewed services there was no copy of the relevant CDM documentation
  • MBS requirements were not met, including that GP Management Plans (GPMPs) were not comprehensive plans for managing patients’ chronic disease and Team Care Arrangements (TCAs) did not always include at least one allied health provider as a participant and, where an allied health provider was included, the TCAs did not always include evidence of two-way collaboration with the provider(s)
  • the GPMPs and TCAs were template-driven and did not always include information specific to each patient
  • some of the patients to whom the practitioner rendered MBS item 721 services did not have an eligible chronic disease
  • there were not always TCAs for the date of service for patients to whom the practitioner rendered MBS item 723 services
  • clinical input was not always adequate

In relation to mental health services, the Committee made findings of inappropriate practice on the basis of one or more of the following for MBS items 2713 and 2727:

  • the patient did not always have a clearly documented mental health disorder and was therefore not eligible for a mental health service
  • the records were inadequate
  • the MBS requirements were not always met including that there was not always sufficient clinical content to support a consultation of at least 20 minutes (MBS item 2713) and, for MBS item 2717, the GPMHTP document was not an adequate General Practitioner Mental Health Treatment Plan
  • the clinical input was not always adequate
  • in some cases, there was no record for the date of service

PSRC 1346

On 12 September 2022 a final determination came into effect regarding a general practitioner. The practitioner was directed to:

  • be reprimanded
  • be counselled
  • repay the amount of $78,018.50 to the Commonwealth
  • be disqualified from rendering MBS item 721, 723, 732 services, and the equivalent telehealth item 92024, 92025 and 92028 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 721, 723 and 732

In relation to the MBS item 721, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS requirements were not met in that some of the patients to whom the service was rendered did not have an eligible chronic disease, the GPMPs were developed without input from the patient, were not comprehensive plans for managing patients’ chronic disease, were template driven and not individualised for patients and with goals identified being vague and unclear
  • a GPMP was not always clinically indicated
  • clinical input was inadequate
  • the medical records were inadequate

In relation to the MBS item 723, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS requirements were not met in that some of the patients to whom the service was rendered did not have an eligible chronic disease, the TCAs were developed without input from the patient and there was no consultation with at least two providers involved in the TCAs, and/or the TCA did not set out the treatments and services for the patients
  • The TCAs were not always clinically indicated
  • the practitioner’s clinical input into TCAs was inadequate
  • the medical records were inadequate the TCAs provided no additional benefit for the patient than a standard referral would have provided.

In relation to the MBS item 732, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS requirements were not met in that the reviews of GPMPs and TCAs were undertaken without input from the patient, there was no assessment of the patient’s conditions and for TCAs there was no communication with other health providers involved in the TCAs
  • It was not appropriate for the practitioner to undertake a review in the circumstances, including because the practitioner was not the patient’s regular GP
  • the medical records were inadequate

C. Federal Court

No decisions concerning PSR were handed down in September 2022

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

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

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in September 2022.

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