PSR Director's Update for February 2020

A. Directors Section 92 agreements effective in February 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 44 and 5060 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering or initiating of MBS items 36, 44, 160, 197, 199, 2713, 5040, 5060, 66596 and 66833, and prescribing of Pharmaceutical Benefits Scheme (PBS) items 3119E and 8254K, and had no concerns in relation to PBS item 3119E. The Director had persisting concerns that:

• the MBS requirements were not always met, including minimum time requirements for MBS items 36, 44, 2713, 5040 and 5060;
• the records were inadequate across all items;
• not all services were clinically indicated, or if they were, the clinical indication for the service was not always recorded; and
• the PBS requirements were not met for the prescribing of PBS item 8254K.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $155,000, to be disqualified from providing MBS items 199, 5060 and 66596 for six months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner billed in excess of 88 percent of their peers, despite having a patient load on the 24th centile. The Director reviewed this practitioner’s rendering and initiating of MBS items 36, 44, 18234, 18236, 30196, 30203, 31363, 31367, 31369, 31376, 45201, 45202, 45445, 45451, 45562 and 45563, and had no concerns in relation to MBS items 31363, 31367, 31369 and 31376. The Director had persisting concerns that:

• the medical records were inadequate across all items, particularly due to the lack of documented patient summaries and patient consent to procedures and use of templates that were not sufficiently individualised for documenting procedures;
• the MBS requirements were not met, including minimum time requirements for consultation items, requisite histopathology for items 30196 and 30203 and annotated clinical reasoning for item 45202. Some items appear to have been billed for services which did not match the description outlined in the MBS descriptor, including trigeminal nerve blocks (item 18234) and neurovascular flaps (items 45562 and 45563); and
• some services were not clinically indicated or the clinical indication was not adequately recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $190,000, to be disqualified from providing MBS items 44, 18234, 18236, 45202, 45445, 45451, 45562 and 45563 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 31358, 31363, 31367 and 31376 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering or initiating of MBS items 36, 44, 18234, 18236, 30195, 30196, 30202, 30219, 31340, 31358, 31363, 31367, 31376, 45201, 45202, 45445 and 45563, and had no concerns in relation to MBS items 31358, 31363, 31367 and 45445. The Director had persisting concerns in relation to the remaining items that:

• the MBS requirements were not met, including minimum time requirements for consultation items, requisite histopathology for items 30196 and 30203, size requirements for item 31376 and annotated clinical reasoning for item 45202. Some items were billed for services which did not match the description outlined in the MBS descriptor, including trigeminal nerve blocks (item 18234), lesion size (item 31376) and neurovascular flaps (item 45563); and
• the services were not all clinically indicated or the clinical indication was not adequately recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $150,000, to be disqualified from providing MBS items 44, 18234, 18236, 30202, 30219, 31340, 45202 and 45563 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 36 and 721 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 707, 721, 723, 732, 2713 and 2717. The Director had persisting concerns that:

• the MBS item requirements were not met. Often the time requirements for MBS items 36, 707, 2713 and 2717 did not appear to be complied with. The requirements for MBS items 721, 723 and 732 were not always met as the practitioner appeared to provide these services to patients who did not have a suitable chronic disease. Where MBS item 723 was billed, there was often no evidence of two way communication with two other healthcare providers;
• not all services were clinically indicated; and
• the practitioner did not always keep adequate records of the services they provided.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $200,000, and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed MBS items 36, 44, 703 and 705 in excess of 98 percent of their peers as well as MBS items 2507 and 2558 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 160, 705, 721, 723, 732, 2507, 2558, 2713 and 5040, and PBS items 1215Y and 8254K, and had no concerns in relation to PBS items 1215Y and 8254K. The Director had persisting concerns that:

• the clinical records were inadequate;
• the MBS requirements were not always met. Often the time requirements for MBS items 36, 44, 705, 2713 and 5040 did not appear to be complied with. Where MBS item 160 was billed, there was often no evidence that the patient was in imminent danger of death;
• not all services were clinically indicated and
• the 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 $180,000, to be disqualified from providing MBS items 44, 160, 705, 732, 2507, 2558 and 2713 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed MBS items 721, 723, 732 and 69333 in excess off 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering or initiating of MBS items 23, 36, 705, 721, 723, 732, 2521, 2552, 5040, 10997, 11610 and 69333. The Director had persisting concerns that:

• the MBS requirements were not always met. Often time requirements for MBS items 36, 705, and 5040 did not appear to be complied with. Where MBS items 721, 723 and 732 were billed, on occasion, the practitioner appeared to provide these services to patients who did not have a suitable chronic condition. Further, where chronic disease management services were billed (MBS items 721, 723 and 732), the documentation was not sufficiently individualised to the patient;
• the practitioner did not maintain adequate records; and
• some services were rendered or initiated without clinical indication.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $710,000, to be disqualified from providing MBS items 36, 705, 721, 723, 2552 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed MBS items 36, 5040 and 5060 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44 and 5040. The Director had persisting concerns that

• the MBS requirements for these items was not always met. The records for MBS items 36, 44 and 5040 often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptor;
• the practitioner did not always keep adequate records of the services they provided; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $140,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner also rendered MBS items 30186, 14100, 32374, 41500, 41647 and 42586 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering or initiating of MBS items 23, 36, 14100, 30186, 30192, 31372, 31374, 31375, 41500, 41647 and 42587, and had no concerns in relation to MBS items 31372, 31374 and 31375. The Director had persisting concerns that

• the MBS item requirements were not always met for MBS items 14100, 30186, 41500 and 42587;
• MBS items 41500 and 41647 were not always clinically indicated.
• the practitioner’s records were often inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $520,000, to be disqualified from providing MBS items 36, 14100, 30186, 30192, 41500, 41647 and 42587 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in February 2020.

C. Federal Court

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

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

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

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in February 2020.