PSR Director's Update for September and October 2020

Published date

17 November 2020

A. Director’s Section 92 agreements effective in October 2020

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 general practitioner

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) item 36 in excess of 99 percent of their peers, despite only having a patient load in the 28th percentile. The Director reviewed this practitioner’s rendering of MBS items of 23 and 36, and prescribing of Pharmaceutical Benefits Scheme (PBS) item 8254K. The Director had persisting concerns that:

the practitioner’s records were inadequate. In particular, the vast majority of records were and brief and difficult to interpret;
MBS requirements were not always met, including the minimum time requirement for MBS item 36 services;
not all services were clinically indicated;
the PBS requirements were not always met; and
PBS item 8254K was prescribed in circumstances where the antibiotic was not clinically indicated.

The practitioner acknowledged they 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 neurologist

During the review period, the practitioner was a high biller of MBS item 11021, 11027 and 18362 services. The Director reviewed this practitioner’s rendering of MBS items 116, 132, 133, 834, 880, 11018, 11021, 11027, 11300, 11713 and 18362. The Director had persisting concerns that:

MBS requirements were not always met, including minimum time requirements for professional attendance items;
not all services were clinically indicated;
the practitioner’s clinical input was not always adequate. For example, some MBS item 18362 services were rendered on the practitioner’s behalf by another medical practitioner; and
the records were often inadequate. In particular, some investigations did not have corresponding reports.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $1,500,000, to be disqualified from providing MBS items 132, 834, 11018, 11021, 11027 and 11713 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS item 35 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 35, 43 and 5028, and had no persisting concerns in relation to MBS item 23. In relation to the remaining items, the Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
records were inadequate and did not always reflect a clinical indication for the service; and
the practitioner’s clinical input was not always adequate. For example, the practitioner conducted some consultations on patients in Residential Aged Care Facilities in public areas.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $195,000, to be disqualified from providing MBS items 35, 43 and 5028 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS items 35 and 5028 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 35, 36 and 5028. The Director had no persisting concerns in relation to MBS items 23 and 36. In relation to MBS items 35 and 5028, the Director had persisting concerns that:

MBS requirements were not always met;
services were not always clinically indicated. Some professional attendance services were provided to patients of a Residential Aged Care Facility daily where no clear indication for the consultation was recorded;
the records were inadequate and did not always include a health summary where appropriate; and
the practitioner’s clinical input was not always adequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $215,000, to be disqualified from providing MBS items 35 and 5028 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner provided a volume of services in excess of 90 percent of their peers, despite having a patient load on the 49th percentile. The Director reviewed this practitioner’s rendering of MBS items 23, 35 and 5028, and had no persisting concerns in relation to MBS items 23. In relation to the remaining items, the Director had persisting concerns that:

MBS requirements were not always met. For example, some MBS item 5028 services did not appear to have been rendered during the after hours period;
the records were inadequate; and
the practitioner’s clinical input was not always sufficient.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $205,000, to be disqualified from providing MBS items 35 and 5028 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS items 233 and 10997 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 53, 54, 225, 233, 721, 723, 732, 10997 and 30071. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
the records were inadequate. In particular, the records for MBS item 30071 services did not adequately describe the procedure and document clinically relevant information; and
the practitioner’s clinical input was not always adequate.

The practitioner acknowledged they 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 54, 225, 721, 723, 732 and 30071 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner provided MBS items 732, 31211, 31362, 56301 and 56507. in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 31211, 31362, 31366, 31367, 56301 and 56507, and prescribing of PBS item 8254K. The Director had persisting concerns that:

MBS requirements were not always met, including where therapeutic procedures were co-billed with consultation items and where there were minimum time requirements;
the practitioner’s clinical input was not always adequate; and
the records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $250,000, to be disqualified from providing MBS items 721, 723 and 732 for 18 months, to be disqualified from providing MBS item 36 for 12 months and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721 and 723 in excess of 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 36, 44, 160, 721 and 723, MBS item 10997 services rendered on the practitioner’s behalf, and prescribing of PBS item 8254K. The Director had no persisting concerns in relation to MBS item 10997. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met. For example, not all patients who received chronic disease management services appeared to have a chronic disease;
the records were inadequate; and
PBS restrictions were not complied with.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $165,000, to be disqualified from providing MBS items 44, 160, 721 and 723 for 12 months, and will be reprimanded by the Director.

An agreement with an optometrist

During the review period, the practitioner rendered MBS items 10913 and 10940 at a variance to their peers. The Director reviewed this practitioner’s rendering of MBS items 10913 and 10940. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
the records were inadequate;
not all services were clinically indicated. In some instances MBS item 10940 was performed based on one scan of a poor quality and no relevant patient history; and
the practitioner’s clinical input was not always adequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $10,000, to be disqualified from providing MBS items 10913 and 10940 for six months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 585, 594, 599 and 5023 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 585, 594, 599 and 5023, and prescribing of PBS items 1215Y and 8254K. The Director had no persisting concerns in relation to MBS items 594 and 5023, or in relation to PBS item 1215Y. In relation to the remaining items, the Director had persisting concerns that:

MBS requirements were not always met, in particular where MBS item 585 and 599 services were rendered, the patient did not appear to require urgent assessment;
the records were inadequate;
the prescribing of PBS item 8254K was not always clinically indicated; and
PBS restrictions were not complied with.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $240,000 and will be reprimanded by the Director.

An agreement with a general practitioner

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

MBS requirements were not always met. For example, the practitioner did not always collaborate with at least two other providers when providing services as MBS item 723; and
the records were inadequate and did not always adequately document patient consent.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $115,000, 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 than 19,000 services. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 2713 and 2715. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
the records were inadequate;
some chronic disease management services were not clinically indicated; and
the practitioner’s clinical input was not always adequate. For example, the practice nurse appeared to complete chronic disease management documentation and it was not always clear that the practitioner reviewed or had any other input into the documentation.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $360,000, to be disqualified from providing MBS item 2715 for 12 months and will be reprimanded by the Director.

An agreement with a cardiologist

During the review period, the practitioner rendered MBS item 132 at a variance to their peers. The Director reviewed this practitioner’s rendering of MBS item 132. The Director had persisting concerns that:

MBS requirements (including minimum time requirements where relevant) were not always met;
the records were inadequate. In some cases, the records were often brief and did not document relevant clinical information; and
not all services were clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $100,000, to be disqualified from providing MBS item 132 for 18 months and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 41647 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23 and 41647. The Director had persisting concerns that:

MBS requirements were not met, particularly where MBS item 23 was co-billed with MBS item 41647; and
the records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $120,000, to be disqualified from providing MBS item 41647 for 12 months and will be reprimanded by the Director.

B. PSR Committee final determinations in September and October 2020

PSR Committee 1127

On 25 September a final determination came into effect regarding a general practitioner who practised in Queensland. The practitioner was directed to repay $1,000 to the Commonwealth.

The direction followed a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in respect of MBS items 36, 43, 44, 5040 and 30029 services.

The Committee was concerned about the practitioner’s record-keeping for some (but only some) longer consultations, and compliance with MBS descriptor requirements for MBS item 30029.

In relation to MBS items 36, 44 and 5040, the Committee found that for some services there was insufficient clinical content recorded to justify an attendance of at least 20 minutes or 40 minutes’ duration, as applicable.

In relation to MBS item 43, which involves attendance on a patient at a residential aged care facility, the Committee accepted that the state of the general record-keeping systems at the facilities attended by the practitioner were poor. Record-keeping was fragmented across different systems and appeared to be incomplete. The Committee found only limited instances of deficient records that could be said to result from the practitioner’s own conduct, having regard to the difficulty working in that system.

MBS item 30029 requires the repair of a wound involving deeper tissue. The Committee found that the practitioner’s records did not disclose that the wound was deep or how deep structures had been addressed.

The Determining Authority’s repayment direction reflects the limited extent of inappropriate practice found by the Committee in the circumstances of the practitioner’s practice.

C. Federal Court

Norouzi v The Director of the Professional Services Review Agency [2020] FCA 1524

On 21 October 2020 the Federal Court allowed an application by a medical practitioner to set aside a final determination of the Determining Authority, in part, and remitted the matter to the Determining Authority to reconsider the practitioner’s submissions regarding the amount of the repayment. While the Court found that the Authority’s determination was not unreasonable, it found that the Authority had not adequately addressed all of the practitioner’s submissions.

The Court dismissed an application to extend time to allow the practitioner to challenge the decision of the PSR Committee noting, amongst other things, the limited merits of the intended substantive application and that the practitioner had delayed, without reasonable cause, in challenging the report of the Committee until he had seen the final determination of the Determining Authority.

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

No matters were referred to the major non-compliance (fraud) division in September or October 2020.

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in September 2020 and two matters were referred to AHPRA in October 2020.