PSR Director's Update for May 2020

Published date

19 June 2020

A. Directors Section 92 agreements effective in May 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 billed Medicare Benefits Schedule (MBS) items 732 in excess of 98 percent of their peers as well as 721 and 723 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 705, 721, 723 and 732 and Pharmaceutical Benefits Scheme (PBS) item 1434L. The Director had no significant persisting concerns in relation to the practitioner’s provision of PBS item 1434L. The Director the following persisting concerns in relation to the remaining services:

the MBS requirements were not always met, including the minimum time requirement for MBS item 705;
where MBS items 705, 721, 723 and 732 were billed, the documentation was not always sufficiently individualised to the patient;
where MBS item 723 was billed, there was often no evidence of two-way communication with two other healthcare providers;
the practitioner’s reviews for MBS item 732 did not involve a re-assessment of the patient’s chronic conditions, consider whether to amend existing goals or team members and did not rectify deficiencies contained in the original documentation;
the practitioner’s prolonged health assessments (MBS item 705) did not always comprehensively assess and manage all of the patient’s conditions;
the practitioner did not always provide adequate clinical input into each service; and
the practitioner did not maintain adequate records.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $95,000 and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS item 739 on more than 200 occasions, which is in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 739, 2712, 2713 and 2715. The Director had no significant persisting concerns in relation to the practitioner’s provision of MBS item 23 and 2715 services. The Director had the following persisting concerns in relation to the remaining services:

for MBS item 23 and 36 services, the progress notes did not always reflect that the practitioner provided sufficient clinical input;
the MBS requirements were not always met, including minimum time requirements for MBS items 36 and 2713;
mental health professional attendances (MBS items 2712, 2713 and 2715), the records were not always sufficiently individualised so as to enable another practitioner to understand what occurred in the consultation, or to take over patient care in reliance on the record;
many of the GP Mental Health Treatment Plans (GPMHTPs) (MBS item 2715) contained identical text across patient records rather than being appropriately individualised for the patient;
reviews of GPMHTPs did not rectify deficiencies in the original plans;

not all case conferences services (MBS item 739) were clinically indicated; and
the practitioner did not maintain adequate records.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $55,000, to be disqualified from providing MBS item 739 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS items 721, 732 and 2712 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS item 721, 723, 732, 2712, 2713, 2715, 5020 and 5040 services. The Director had no significant persisting concerns in relation to services provided as MBS item 5020. The Director had the following persisting concerns in relation to the remaining services:

MBS item requirements were not met, including minimum time requirements for MBS items 2713, 2715 and 5040;
With respect to MBS item 721, 723 and 732 services, patients did not always have a chronic disease which would have benefitted from a chronic disease management service and for MBS item 723 there was often no evidence of two-way collaboration with two other healthcare providers. The practitioner’s reviews of GP management plans and Team Care Arrangements (MBS item 732) often did not constitute a meaningful review and did not rectify deficiencies evident in the original documentation;
the practitioner did not maintain adequate records, including documenting patient consent for chronic disease management services and preparation of mental health treatment plans.

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, 732 for 12 months, to be disqualified from providing MBS items 2712 and 2715 for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered level C professional attendances (MBS items 36 and 43) in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 43, 2713 and 5040. The Director had persisting concerns that:

the practitioner did not maintain adequate records. Often records were very brief and did not always document relevant clinical information so as to enable another practitioner to understand what occurred in the consultation;
MBS requirements were not always met and the records contained insufficient clinical input to justify the minimum time requirements outlined in the MBS item descriptors; and
some services provided at residential aged care facilities were not clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $180,000, to be disqualified from providing MBS items 43, 2713, 5040 for 3 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS items 36 and 5040 in excess of 99 percent of peers. The Director reviewed this practitioner’s rendering of MBS items 36, 2713 and 5040, and PBS items 3119E and 8254K. The Director had persisting concerns that:

MBS requirements were not always met. The reviewed records for MBS items 36, 5040 and 2713 often contained insufficient clinical input to justify the minimum time requirements outlined in the respective MBS item descriptors;
the practitioner did not maintain adequate records of level C professional attendances, billed as MBS items 36 and 5040;
there was not always a clear clinical indication for prescribing antibiotics and PBS item 8254K was prescribed outside of the PBS restrictions.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $245,000, to be disqualified from providing MBS items 5040 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner billed MBS items 721, 723, 732, 2712, 2717, 11506 and 11610 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 707, 721, 723, 732, 2712, 2717, 11506 and 11610, and PBS items 2622B and 3162K, and had no significant persisting concerns in relation to MBS items 11610. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met, including minimum time requirements for MBS item 36, 44, 707 and 2717 services;

the practitioner did not maintain adequate or contemporaneous records;
the practitioner did not always provide adequate clinical input into each service;
MBS item 721 services did not contain a comprehensive plan;
the practitioner did not consult with at least two other providers for the purposes of providing MBS item 723 services;
MBS item 732 services did not involve a re-assessment of the patient’s chronic condition;
the services billed as MBS item 2712 did not relate to a mental disorder;
the practitioner rendered diagnostic procedures (MBS item 11506) in the absence of sufficient clinical indication and in circumstances were the MBS requirements were not always met; and
there was not always a clear clinical indication for the prescribing of PBS items 2622B and 3162K and the practitioner did not always appropriately manage patients receiving these medications.

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 general practitioner

During the review period, the practitioner billed MBS items 721, 723 and 732 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723 and 732, and PBS items 2363J, 2622B, 3133X, 3162K, 8501K, 8611F and 8785J, and had no concerns in relation to MBS items 23. The Director had persisting concerns in relation to the remaining items that:

the MBS requirements were not always met for chronic disease management services (MBS items 721. 723 and 732) as required documents were not always created or completed;
the practitioner did not maintain adequate records;
the practitioner prescribed drugs of dependence with inadequate patient management or review, and did not provide sufficient clinical input when prescribing these medications;
there was not always a clear clinical indication for initiation or continued prescribing of medications under the PBS;
the practitioner prescribed drugs of addiction (PBS items 8611F and 2363) outside relevant PBS requirements and without required state authority; and
the practitioner’s records across all PBS items were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $185,000, 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 physician

During the review period, the practitioner billed MBS item 11610 on over 4,000 occasions and rendered MBS item 11610 in association with MBS item 11700 to the same patient on the same day on 99 percent of occasions they were rendered. The Director reviewed this practitioner’s rendering of MBS items 132, 133, 11610 and 11700. The Director had persisting concerns that:

the MBS requirements for MBS items 132 and 133 were not always met, including the minimum time requirements outlined in the respective MBS item descriptors. In particular, the reviewed records often did not reflect that the practitioner had developed a separate treatment and management plan of significant complexity or that the practitioner reviewed and modified a treatment and management plan;
diagnostic procedures and investigations (MBS items 11610 and 11700) were not always clinically indicated; and
the practitioner did not maintain adequate records.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $280,000, to be disqualified from providing MBS items 132, 133 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed chronic disease management services to over 31 percent of all patients and rendered MBS items 721, 723 and 732 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 732, 2713 and 2717, and PBS items 1891M and 8254K. The Director had persisting concerns that:

for MBS items 2713 and 2717 services, the practitioner’s records often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptors;
the practitioner did not maintain adequate records for MBS services; and
in respect of the prescribing of PBS items 1891M and 8254K, there was not always a clear indication for prescribing antibiotics and the respective PBS requirements were not always met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $340,000, to be disqualified from providing MBS items 721, 723, 732 and 2717 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered 79 percent of all professional attendances as either level C or D attendances and rendered MBS items 36 and 44 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 721 and 723. The Director had persisting concerns that:

the MBS requirements were not always met, including minimum time requirements for MBS items 36 and 44. Where MBS items 721 services were billed, the documentation was not sufficiently comprehensive and/or individualised to the patient’s chronic condition(s) or terminal illness. For MBS item 723 there was often no evidence of two-way communication with at least two other healthcare providers;
the practitioner did not maintain adequate records.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $390,000, to be disqualified from providing MBS items 44, 721 and 723 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, this practitioner billed MBS items 721 and 723 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 2712, 2713 and 2715 and PBS item 1644M. The Director had no significant persisting concerns in respect of services billed as MBS item 23 and PBS item 1644M. The Director had persisting concerns in relation to the remaining items that:

the MBS requirements were not always met. The records for MBS items 36, 2713 and 2715 often contained insufficient clinical input to justify the minimum time requirement outlined in the respective MBS item descriptor. For MBS items 721 and 723, patients did not always have a suitable chronic disease. Further, the practitioner’s reviews for MBS items 732 and 2712, were often not meaningful, did not always rectify the deficiencies of the original documentation and where related to a TCA did not demonstrate collaboration with at least two other providers; and
the practitioner did not maintain adequate records.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $220,000, to be disqualified from providing MBS items 721, 723, 732, 2712 and 2715 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered more than 15,500 total services which is in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 53, 185, 701 and 5020. The Director had persisting concerns that:

MBS requirements were not always met;
the medical records were inadequate across all items. In particular, the records for professional attendances (MBS items 53, 185 and 5020) were often brief and did not document important clinical information which may prevent another practitioner from effectively taking over care of the patient; and
the practitioner did not always provide adequate clinical input into each service or alternatively, failed to document their clinical input.

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 701 for 12 months, and will be reprimanded by the Director.

An agreement with a dentist

The Director reviewed this practitioner’s rendering of Child Dental Benefits Schedule (CDBS) items 88011, 88161, 88162 and 88572, and had no significant persisting concerns in relation to MBS items 88011. The Director had persisting concerns in relation to the remaining items that:

the practitioner did not maintain adequate records; and
procedures provided by the practitioner were not always clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $80,000, to be disqualified from providing CDBS items 88161 and 88162 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner’s ratio of MBS item 36 to MBS item 23 services was at significant variance to the ratio of these items nationally. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 732 and 2713, and PBS items 1215Y, 2089Y, 2363J, 2622B, 2723H, 3133X, 3162K, 8254K, 8501K, 8525Q, 8611F and 8785J. The Director had persisting concerns that:

the MBS item requirements were not always met, including minimum time requirements outlined in the MBS item descriptor for MBS items 36 and 2713;
where chronic disease management services (MBS items 721 and 732) were billed, there was insufficient clinical input and the documentation was not sufficiently comprehensive or individualised to the patient. For MBS item 732, there was often no evidence of consultation with at least two other healthcare providers to review all the matters set out in the team care arrangement, as required by the item descriptor;
the practitioner did not always maintain adequate records;
in respect to the prescribing of medications under the PBS, there was not always a clear clinical indication for initiation or continued prescribing of these medications and the records often did not reflect sufficient clinical input;
the practitioner did not appropriately manage patients at risk of substance abuse; and
PBS items 2363J and 8254K were prescribed outside the relevant PBS requirements.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $175,000, to be disqualified from providing MBS items 721, 732, 2713 for 12 months, to be disqualified from providing MBS item 36 for 6 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in May 2020.

C. Federal Court

No decisions from the Federal Court were handed down in May 2020.

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

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

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in May 2020.