PSR Director's Update for January 2022

Published date

17 February 2022

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

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

An agreement with a general practitioner

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 36, 44 and 707 in excess of 98% of their peers. The Director reviewed this practitioner’s provision of MBS items 36, 44, 707, 721, 723, 732 and 10997. The Director had persisting concerns that:

the MBS requirements were not always met. This included time requirements and some of the reviewed CDM documents not being comprehensive plans sufficiently individualised to the patient’s condition, goals and needs
the practitioner’s records were inadequate. For example, the practitioner’s record keeping practices would not allow another practitioner to safely assume care
the practitioner’s clinical input was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with the provision of these items of concern. The practitioner agreed to repay $135,000, to be disqualified from providing MBS item 732, 92028 and 92072 services for a period of 12 months and to be disqualified from providing MBS item 721, 723, 92024, 92025, 92068 and 92069 services for a period of 6 months, and will be reprimanded by the Director.

An agreement with a cardiologist

During the review period, the practitioner rendered MBS items 110, 117 and 133 in excess of 98% of their peers. The Director reviewed this practitioner’s provision of MBS items 110, 116, 117, 132, 133, 11700, 11709, 11712, 55113 and 55116. The Director had no persisting concerns about MBS item 116 and 11700 services. The Director had persisting concerns in relation to the other items that:

the MBS requirements were not met, including that the services performed were not of sufficient complexity to justify the billing in respect of MBS items 132 and 133 and minimum time requirements were not met
the practitioner’s records were inadequate
not all investigations initiated were clinically indicated. For example, in many instances it appears that tests were performed routinely even if the patient did not present with any new symptoms.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering these items of concern. The practitioner agreed to repay $550,000, to be disqualified from providing MBS items 117, 132 and 133 services for 12 months and will be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner co-claimed MBS head and spine Magnetic Resonance Imaging (MRI) services in excess of 99% of their peers. The Director reviewed this practitioner’s provision of MBS items 104, 105, 63001, 63007, 63046, 63055, 63167, 63173 and 63176. The Director had persisting concerns that:

consultation items were systematically billed whenever an attendance was required for a diagnostic imaging service. If a separate consultation was performed the service was not clinically indicated, the MBS requirements were not met and there was no adequate or contemporaneous record
multiple head and spine MRI items were co-billed for a single service or where not all services were clinically indicated
appropriate informed consent was not always obtained for interventional procedures performed in association with imaging or the administration of contrast
the practitioner’s records were inadequate.

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 MBS items 104, 105 and 63055 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

Three final determinations came into effect in January 2022.

PSR Committee No. 1174

On 27 January 2022 a final determination came into effect regarding a medical practitioner, Dr Nicholas Doong, who practised in Enfield, New South Wales. The practitioner was directed to:

be reprimanded
be counselled
repay $332,532.83 to the Commonwealth and
be disqualified from rendering MBS items 44 and 721 for a period of 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 services rendered as MBS items 36, 44, 721, 2525, 2713, 66542, 66719 and 69333.

In relation to MBS items 36 and 44 services the Committee made findings of inappropriate practice on the basis of:

failure to comply with MBS requirements, particularly the requirement for an attendance of at least 20 or 40 minutes (as applicable)
failure to maintain an adequate record of the services provided
the clinical input provided into the service was inadequate
requests for pathology tests were not clinically indicated.

In relation to MBS item 721 the Committee made universal findings of inappropriate practice. The findings were on the basis of:

the patient was not in attendance for the service
the MBS requirements were not met, including that the General Practitioner Management Plan was not a comprehensive plan that was individualised to the patient
the medical records were inadequate.

In relation to MBS item 2525 services the Committee made findings of inappropriate practice on the basis of:

failure to meet the MBS requirements
the clinical input provided into the service was inadequate
failure to maintain an adequate record of the services provided.

In relation to MBS item 2713 services the Committee made findings of inappropriate practice on the basis of:

failure to meet MBS requirements
failure to adequately assess the patient’s mental health
the clinical input provided into the service was inadequate
failure to maintain an adequate record of the services provided.

With respect to services rendered as MBS items 66542, 66719 and 69333, the Committee made findings of inappropriate practice on the basis that the tests were not clinically indicated.

PSR Committee No. 1218

On 14 January 2022 a final determination came into effect regarding a medical practitioner, Dr Navin Naidoo, who practised in Gympie, Queensland. The practitioner was directed to:

be reprimanded
be counselled
repay $548,286.21 to the Commonwealth and
be disqualified from rendering MBS items 36 and 37 for a period of three months, MBS item 47 for a period of 12 months and MBS items 721 and 723 for a period of 18 months.

In relation to MBS items 36, 37 and 47 services the Committee made findings of inappropriate practice based on one or more of the following:

the medical record was inadequate
the MBS item requirements were not met.

In relation to MBS item 37 services, the Committee also made findings of inappropriate practice on the basis that the practitioner’s clinical input was inadequate and his clinical management was inappropriate. In relation to MBS items 47 services the Committee also made findings of inappropriate practice based on one or more of the following:

there was no evidence in the record to suggest the practitioner provided a professional attendance for the service
consultations were not clinically indicated.

In relation to MBS item 721 and 723 services the Committee made findings of inappropriate practice based on one or more of the following:

the medical record was inadequate
the practitioner provided insufficient clinical input into the service.

In relation to MBS item 721 services the Committee also made findings of inappropriate practice based on one or more of the following that:

the MBS requirements were not met in that the General Practitioner Management Plans were not comprehensive written plans describing the patient’s healthcare needs, health problems and relevant conditions
the General Practitioner Management Plans did not contain a baseline assessment of the patient’s chronic disease to enable progress to be measured
the patient was not eligible for a Chronic Disease Management service.

In relation to MBS items 723 services the Committee also made findings of inappropriate practice based on one or more of the following:

the MBS requirements were not met as the practitioner did not adequately collaborate with at least two different practitioners, each of whom was to provide a different kind of treatment or service
the Team Care Arrangement (TCA) documents were not comprehensive or personalised to the patient
no TCA document was located for the date of the service.

In relation to MBS items 56807, 61307, 66596, 66716 and 69333 services the Committee made findings of inappropriate practice based on one or more of the following:

there was no documented clinical indication for the test
the medical record was inadequate
there was insufficient clinical input into the service.

PSR Committee No. 1320

On 12 January 2022 a final determination came into effect regarding a general practitioner, who practiced in Melbourne, Victoria. The practitioner was directed to:

be reprimanded
be counselled
repay $301,490.02 to the Commonwealth and
be disqualified from rendering MBS items 721, 723 and 732 for a period of 12 months.

In relation to MBS items 23 and 5020 services the Committee made findings of inappropriate practice on the basis of:

failure to comply with MBS requirements
failure to maintain an adequate record of the services provided
failure to provide adequate clinical input into the service.

In relation to Chronic Disease Management (CDM) services, the Committee’s findings of inappropriate practice were widespread. In relation to MBS item 721, 723 and 732 services the findings were made on the basis on one or more of the following:

patients were not in attendance
patients did not consent to the services
the services were not clinically indicated
the medical records were inadequate
the MBS requirements were not met, including that the General Practitioner Management Plan was not a comprehensive plan that was individualised to the patient
other attendance items were impermissibly co-billed
the clinical input provided into the service was inadequate.

C. Federal Court

No decisions concerning PSR were handed down in January 2022.

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

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

E. Referrals to Ahpra(106XA/B)

Four matters were referred to Ahpra in January 2022.