PSR Director's Update for October 2021

Director’s decision to not conduct a review under s88A of the Act

The Director decided not to conduct a review under s88A of the Act in respect of one referral in October 2021.

A referral was received from the Chief Executive Medicare in respect of a general practitioner who had been identified as rendering a prescribed pattern of services, i.e., rendering more than 80 professional services on more than 20 days during a twelve month period (also known as the 80/20 rule). Medicare is required to refer breaches of the 80/20 rule to the Director of PSR. The Director decided under s88A(1) of the Health Insurance Act 1973 (Act) not to undertake a review as it did not appear that there was a possibility that the practitioner had engaged in inappropriate practice in providing services during the Review Period.

The Director accepted that there were exceptional circumstances for each of the days when more than 80 professional attendances were rendered during the relevant period which fell between March and June 2020, after the onset of the COVID-19 pandemic. The Director was satisfied that, as a result of the pandemic response, on each of these days there was an unusual occurrence causing an unusual level of need for relevant services. This was due to heavy demand by patients based on recommendations of federal and state health authorities for influenza vaccinations at a time when, additionally, the availability of medical services was significantly reduced in the community.  The Director accepted that the practitioner provided appropriate clinical input into each of the services provided and had reasonably billed for a short consultation for each vaccination service.

A. Director’s Section 92 agreements effective in October 2021

In October 2021, no s92 agreements came into effect.

B. PSR Committee final determinations

One final determination came into effect in October 2021

PSR Committee No. 1298

On 25 October 2021 a final determination came into effect regarding Dr Aamir Siddiqui, a medical practitioner who primarily practised at Beaudesert in Queensland. The practitioner was directed to:

• be reprimanded
• be counselled
• repay $518,998.73 to the Commonwealth and
• be disqualified from rendering:
  • MBS item 36 and 30192 services for a period of six months
  • MBS item 585, 588, 591, 594, 599, 600, 721, 723 and 732 services for a period of twelve 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 23, 36, 591, 597, 598, 721, 723, 732 and 30192.

The partial disqualification applies to MBS items 585, 588, 594, 599 and 600 as from 1 March 2018 these items replaced MBS item 597 and 598 on the MBS. The disqualification will have substantially the same effect as a disqualification from MBS item 597.

In relation to MBS items 23 and 36 the Committee made findings of inappropriate practice on the basis of:

• failure to comply with MBS requirements, particularly time requirements for MBS item 36 services
• failure to maintain an adequate record of the services provided
• the clinical input provided into the service was inadequate.

In relation to MBS items 591, 597 and 598 the Committee made findings of inappropriate practice on the basis of:

• failure to comply with MBS requirements as services were not rendered to patients who required urgent assessment or treatment as required by the MBS item descriptor
• failure to maintain an adequate record of the services provided.

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 that:

• the regulatory requirements were not met
• the clinical input provided into the services was inadequate
• there was no clinical indication to perform the CDM service
• the medical records were inadequate
• the CDM documentation would not assist either the practitioner themselves or another practitioner, or the patient, to manage the patient’s chronic conditions on an ongoing basis.

In relation to MBS item 30192 the Committee made findings of inappropriate practice on the basis that:

• there was no record to justify a separate MBS item being billed in relation to the attendance or no clinical input provided to justify a separate MBS service being billed in relation to the attendance
• the clinical input was inadequate
• the medical record was inadequate.

C. Federal Court

No decisions concerning PSR were handed down in October 2021.

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

No matters were referred to the major non-compliance (fraud) division in October 2021.

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in October 2021.