PSR Director's Update for February 2021

Published date

25 March 2021

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

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

An agreement with a cardiologist

During the review period, the practitioner rendered a volume of total and daily services in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of Medicare Benefits Schedule (MBS) items 132, 133, 162, 163, 11503, 11610, 11612, 11700, 11709, 11712 and 55113. The Director had persisting concerns that:

MBS item requirements were not always met, including the minimum time requirements
in respect to MBS item 162 and 163 services, the majority of patients were not in imminent danger of death
not all services were clinically indicated. For example, there was not always a focused patient history or relevant examination revealing a clinical justification for performing MBS items 11503, 11610, 11612, 11709 and 11712 tests and
the records were inadequate as there was not always evidence of test results or an interpretation of the results.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $750,000, to be disqualified from providing MBS items 132, 133, 162, 163, 11503, 11610 and 11612 for 24 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner was in excess of 99 percent of other active general practitioners in Australia in their rendering of Chronic Disease Management (CDM) services as MBS items 721 and 723. The Director reviewed this practitioner’s rendering of MBS items 721, 723 and 732, and Pharmaceutical Benefits Schedule (PBS) item 8785J. The Director had persisting concerns that:

the practitioner’s clinical input was inadequate
none of the reviewed records reflected the requirements of the MBS item 721 descriptor were met
the Team Care Arrangements (TCA) billed as MBS item 723 did not always contain evidence of two-way communication with at least two other health providers
the records were inadequate. For example, the Chronic Disease Management documentation was often template-driven with little individualised content and did not record patient consent and
the practitioner’s prescribing was not always clinically indicated and the records did not always demonstrate appropriate management and monitoring of patients receiving this medication.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $140,000, to be disqualified from providing MBS items 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered MBS excision items 31357, 31358, 31360, 31362, 31364, 31365, 31366 and 31367 in excess of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 30026, 30032, 31360, 31362, 31364, 31366 and 45201. The Director had persisting concerns that:

the reviewed records which related only to routine after-care did not support a separate Level B consultation
the records were inadequate. Due to the brevity of the records, the practitioner’s records for the reviewed service did not demonstrate that other less invasive methods of treatment for the patient were considered
MBS requirements were not always met with respect to therapeutic procedure items. For example, in some of the reviewed records, the excised lesion was excluded from the item descriptor
the records did not reflect that patient consent had been documented and
not all services were clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $50,000, to be disqualified from providing all services in respect of which an MBS benefit would be payable for 36 months, and will be reprimanded by the Director.

An agreement with a general physician.

During the review period, the practitioner rendered MBS items 132 and 133 in excess of 97 and 99 per cent of peers respectively. The Director reviewed this practitioner’s rendering of MBS items 132 and 133. The Director had persisting concerns that:

MBS item requirements were not always met. For example, the plans did not always appear to involve a comprehensive multi or detailed system assessment and the patients did not always appear to have at least two morbidities that warranted a treatment and management plan of significant complexity, as required by the MBS item descriptor
not all services were clinically indicated and
the records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $50,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered MBS item 721 and 723 services in excess of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723 and 732. The Director had persisting concerns that:

for many MBS item 721 and 723 services, there was no evidence of the patients having been in attendance on the date of service
the records were inadequate. For example, the goals in CDM documentation were generic and had not been individualised to reflect the patient’s particular condition or specific care needs
MBS requirements were not always met. In respect of MBS item 723, none of the reviewed records reflected any of the requirements outlined by the MBS item descriptor, including two-way communication with at least two other providers for the purposes of developing the TCA and
many of the documents were not signed and it was not always clear whether patient consent was obtained.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $140,000, to be disqualified from providing MBS items 721, 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered more services as MBS item 721 and 732 than at least 99 per cent and 98 per cent of peers, respectively. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 732 and 41647, and had no concerns in relation to MBS item 723. The Director had persisting concerns that:

MBS requirements were not always met. For example, the practitioner did not always adequately record patient consent when rendering CDM services and in one of the reviewed MBS item 721 services, the patient did not appear to have a chronic disease
the practitioner charged co-payment for MBS item 41647 services in some circumstances where the patient had been bulk-billed
MBS item 41647 services were performed by a practice nurse on some occasions rather than by the practitioner themself
the records were inadequate and
the item descriptor was not met and services were not always clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $110,000, to be disqualified from providing MBS item 41617 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner was at variance to their peers in the rate and pattern of Residential Aged Care Facilities (RACF) consultation items rendered. The Director reviewed this practitioner’s rendering of MBS items 35, 5028, 90001 and 90035, and PBS item 3132W, and had no concerns in relation to PBS item 3132W. The Director had persisting concerns that:

MBS requirements were not always met. For example, when rendering MBS item 35, it did not always appear that the practitioner took an adequate patient history or performed an examination, when these were clinically relevant tasks
the records were often inadequate and
the practitioner billed MBS items 35 and 90001 in a manner that was excessive and inconsistent with the remuneration rules for those items. The practitioner worked at two practices which were co-located with an RACF and billed these item numbers repeatedly for multiple patients in a day at the RACF.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $260,000 and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered more services as MBS items 160, 721, 723, 732, 2712 and 2717 than at least 99 per cent of peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 160, 721, 723, 732, 2712, 2713, 2717, 5020 and 5040, PBS item 8254K, and the provision of a prescribed pattern of services (the 80/20 rule). The Director had persisting concerns that:

the MBS requirements were not always met, including minimum time requirements
the practitioner rendered 80 or more professional attendances on 40 days during the review period
the records were inadequate across all reviewed services. For example, the practitioner’s progress notes appeared to contain similar or identical text in respect of examinations of patients and did not always document patient consent and
the practitioner did not always provide sufficient clinical input in prescribing PBS item 8254K and prescribed PBS item 8254K in circumstances where resistance to amoxicillin was not suspected or proven.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $750,000, to be disqualified from providing MBS items 36, 721, 723, 732, 2712, 2713 and 2717 for 12 months, and will be reprimanded by the Director.

An agreement with a neurologist.

During the review period, the practitioner rendered a volume of total and daily services in excess of 99 per cent of their peers. The Director reviewed this practitioner’s rendering of MBS items 11004, 11005 and 11709, and had no persisting concerns in relation to MBS item 11004. The Director had persisting concerns that:

there was no process to determine which diagnostic tests were clinically indicated
technicians were inadequately supervised when reviewing EEG and ECG data and developing reports
there was no report completed in respect of every investigation billed to Medicare
not all services were clinically indicated and
some services were billed prior to each service being completed.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $246,081 and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in February 2021

C. Federal Court

No decisions concerning PSR were handed down in January 2021

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

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

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in February 2021.