PSR Director's Update for February 2022

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

Two agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in February 2022.

An agreement with a general practitioner

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 51, 90043 and 90051 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 51, 2713, 90035, 90043 and 90051. The Director had persisting concerns that:

• the MBS requirements were not always met.  This included minimum time requirements not being met (where applicable) and/or their being a failure to take a detailed patient history, perform a clinical examination or implement a management plan where this was clinically indicated
• the practitioner’s clinical input was inadequate
• some services provided in Residential Aged Care Facilities (RACFs) were billed to patients who were deceased and some records for attendances at RACFs were not contemporaneous
• the practitioner’s records were inadequate. For example, the practitioner’s record keeping practices would not allow another practitioner to take over care of patients.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering these items of concern. The practitioner agreed to repay $277,312, to be fully disqualified from Medicare for a period of 3 months, to be disqualified from providing MBS items 36, 44, 51, 2713, 90035, 90043 and 90051 for a period of 12 months and will be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner rendered MBS items 104, 55850, 57521, 57527, 57712, 57715 and 58115 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 57521, 57527, 57712, 57715 and 58115. The Director had persisting concerns that:

• for MBS item 104, the records did not reflect a consultation service being performed separate to the other item(s) billed
• multiple diagnostic imaging items were co-billed that were not clinically indicated or requested and which did not meet the MBS requirements
• additional charges were raised for some diagnostic imaging services by way of billing for injection consumables.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $470,000, to be disqualified from providing MBS item 104 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations came into effect in February 2022.

PSR Committee No. 1235

On 25 February 2022 a final determination came into effect regarding Dr Haralambos Kypreos, a medical practitioner, who practised in Adelaide, South Australia. The final determination relates to a review period of practice from 1 November 2016 to 31 October 2017.  The practitioner was directed to:

• be reprimanded
• be counselled
• repay $249,095.08 to the Commonwealth and
• be disqualified from rendering:
  • MBS items 36, 2713 and 5040 (and the equivalent telehealth items, 91891, 92115 and 92127) for a period of 6 months
  • MBS items 44, 707, 2717, 2725, (and the equivalent telehealth items, 91802, 92117, 91819 and 91843) for 18 months.

These directions followed from a final report of a PSR Committee, which concluded that the practitioner had engaged in widespread inappropriate practice in connection with services rendered as MBS items 36, 44, 707, 2713, 2717, 2725 and 5040.

In relation to professional attendances items, MBS items 36, 44, and 5040, the Committee made findings of inappropriate practice on the basis of one or more of the following:

• there was no consultation note or corroborative evidence to support the patient had attended and a professional service was provided on the date of service
• the medical records were inadequate
• the MBS requirements were not met
• the clinical input provided into the service was inadequate
• for MBS items 36 and 5040, there was insufficient clinical detail or input recorded to support the minimum attendance time of at least 20 minutes
• for MBS item 44, there was insufficient clinical detail or input recorded to support the minimum attendance time of at least 40 minutes.

In relation to MBS item 707, prolonged health assessment lasting at least 60 minutes, the Committee made findings of inappropriate practice on the basis:

• the MBS requirements were not met, including the requirement for a health assessment document
• the practitioner did not perform a health assessment service as contemplated by MBS item 707
• the clinical record was inadequate in documenting a health assessment service.

In relation to mental health professional attendance services under MBS items 2713, 2717 and 2725, the Committee made findings of inappropriate practice on the basis of one or more of the following:

• there was no consultation note or corroborative evidence to support the patient had attended and a professional service provided on the date of service
• the MBS requirements were not met, including evidence of treatment of a mental health disorder
• the clinical input provided into the service was inadequate
• the medical records were inadequate
• for 2725 services, the practitioner failed to adequately document the content of focussed psychological strategies delivered
• items 2725 and 2717 were often co-billed where the records did not reflect the combined minimum time requirements of at least 80 minutes.

PSR Committee No. 1271

On 25 February 2022 a final determination came into effect regarding a medical practitioner who practised in regional Queensland. The practitioner was directed to:

• be reprimanded
• be counselled
• repay $359,366.21 to the Commonwealth and
• be disqualified from rendering MBS item 585, 588, 591 and 594 (and the equivalent telehealth item 92210) services for a period of 6 months.

These directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in connection with services rendered as MBS items 597, 599 and 5023, being for urgent after-hours attendances and Level B attendances, during the review period.

The Committee’s findings for the MBS item 597 and 599 services in relation to which the practitioner was found to have engaged in inappropriate practice were for one or more of the following reasons:

• the regulatory requirements for billing the items were not met, in that the patient did not require urgent treatment or assessment
• the practitioner’s clinical input into the services was inadequate
• the medical record was inadequate, including that in some cases the Committee was unable to determine from the record whether the patient required urgent treatment.

The Committee’s findings for the MBS item 5023 services in relation to which the practitioner was found to have engaged in inappropriate practice were for one or more of the following reasons:

• the MBS requirements were not met
• the practitioner’s clinical input in to the services was inadequate, and/or
• the medical record was inadequate, including that the patient’s presenting symptoms were described inadequately and/or the record provided an inadequate account of the clinical reasoning which led to the practitioner’s diagnosis and treatment of the patients’ presenting complaints.

The disqualification reflects that MBS items 597 and 599 are no longer on the MBS Schedule and have in effect been replaced by MBS items 585, 588, 591 and 594 and includes the relevant telehealth equivalent MBS item 92210. The directions, including the repayment amount, reflect the extent of the role of the practitioner’s employer in influencing the services rendered.

C. Federal Court

No decisions concerning PSR were handed down in February 2022.

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

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

E. Referrals to AHPRA (106XA/B)

Five matters were referred to AHPRA in February 2022.