PSR Director's Update for October 2019

Published date

11 November 2019

A. Director’s Section 92 agreements effective in October 2019

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

The practitioner billed more than 15,000 services in the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 30192, 30202, 31358, 31361, 31363, 31365, 31367, 31373, 31375 and 31376, and Pharmaceutical Benefits Scheme (PBS) items 3119E and 8254K, and had no concerns in relation to PBS items 3119E and 8254K. The Director had persisting concerns that:

the practitioner’s handwritten notes were very brief and difficult to read;
the practitioner did not document the number, location, size or details of lesions excised;
the practitioner did not record any details of any billed procedures;
the practitioner did not record consent for procedures; and
co-billed consultations often contained only one or two words as their entire entry.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $460,000 and will be reprimanded by the Director.

An agreement with a respiratory and sleep medicine specialist

During the review period, the practitioner billed MBS item 12203 on more than 2000 occasions (>98 centile compared to peers) and MBS item 12250 on 2300 occasions (>97 centile compared to peers). The Director reviewed this practitioner’s rendering of MBS items 12203 and 12250. The Director had persisting concerns that:

the practitioner did not always provide adequate clinical input into all services;
appropriate quality assurance procedures were not in place with respect of the practitioner’s rendering of sleep study services;
the MBS requirements were not always met, including ensuring referrals were assessed prior to conducting the sleep study; and
the practitioner provided services that 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 $725,000 and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed over 23,000 services during the year under review. The Director reviewed this practitioner’s rendering of a prescribed pattern of services as well as their provision of MBS items 23, 36, 721, 723, 732, 2715, 5020, 5040, 66596, 66833 and 66839 and PBS items 10104T and 3119E, and had no concerns in relation to PBS items 10104T and 3119E. The Director had persisting concerns that:

the practitioner rendered a prescribed pattern of services (80 or more professional attendances on each of 30 days) during the review period in circumstances that were not exceptional;
not all services reviewed had contemporaneous records and the practitioner appeared to have made additions or alterations to some records non-contemporaneously;
aside from any non-contemporaneous entries, the practitioner’s medical records were inadequate;
MBS item requirements were not met for all services, including minimum time requirements (where relevant);
not all services were clinically indicated; and
the practitioner’s clinical input for some services was inadequate and/or inadequately recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern and in connection with rendering a prescribed pattern of services. The practitioner agreed to repay $300,000, to be disqualified from providing MBS items 721, 723, 732, 2715 and 66839 for 12 months and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed more than 17,000 services, including billing more than 80 professional attendances on more than 20 days during the review period. On some days more than 90 professional attendances were billed. The Director reviewed this practitioner’s provision of MBS items 23, 36, 721, 723, 5020, 5040, 56022, 63551, 63560, 66596 and 66833 and PBS items 3119E and 8254K. The Director had persisting concerns that the practitioner rendered a prescribed pattern of services on 23 days during the review period in circumstances that were not exceptional, and in relation to MBS items 721, 723 and 66833, and PBS item 8254K, that the practitioner:

did not keep adequate medical records;
provided services that did not always meet the MBS requirements;
provided services that were not clinically necessary; and
prescribed PBS item 8254K outside the PBS restriction.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing the MBS items of concern and in connection with rendering a prescribed pattern of services. The practitioner agreed to repay $110,000 and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner billed MBS item 36 in excess of 99 percent of their peers, despite having a patient load on the 51st centile. The practitioner billed long consultations 15x more often than the peer average. The Director reviewed this practitioner’s rendering of MBS items 36, 44 and 5040, and had no concerns in relation to MBS items 5040. In relation to items 36 and 44, the Director had persisting concerns that:

MBS item requirements were not met, including the minimum time requirements;
records were inadequate;
clinical input was either inadequate, or inadequately recorded; 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 $175,000 and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed in excess of 88 percent of their peers, despite have a patient load on the 40th centile during the review period. The practitioner billed level C and level D consultations 5x and 56x more often than the peer average. The Director reviewed this practitioner’s provision of MBS items 36, 44, 160, 707, 721, 723, 732, 900, 2558, 2712, 2713, 2717 and 11610, and PBS items 3162K and 8254K, and had no concerns in relation to MBS items 900, 2712 and 11610, and PBS items 3162K and 8254K. The Director had persisting concerns that:

MBS requirements were not met, including minimum time requirements (were relevant);
medical records were inadequate;
clinical input was inadequate; and
some services provided 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 $380,000, to be disqualified from providing MBS items 44, 160, 707, 723, 732 and 2717 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations became effective in October 2019.

C. Federal Court

No decisions from the Federal Court were handed down in October 2019.

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

No matters were referred to the major non-compliance (fraud) division in October 2019.

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in October 2019.