PSR Director’s Update for October 2022

A. Director’s section 92 agreements effective in October 2022

10 agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in October 2022:

An agreement with a radiologist

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 56107, 56412, 57007 in association in excess of 99 percent of peers. The Director reviewed this practitioner’s rendering of MBS items 56107, 56412 and 57007. The Director had persisting concerns that:

• not all CT items claimed were requested or clinically indicated
• a complete service was not always provided for each MBS item service billed including reporting on each relevant scan performed

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $425,000 and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS telephone attendance items 91809, 92128 and 92216 and prescribed Pharmaceutical Benefits Scheme (PBS) items 1394J, 11276L, 8064K, 8519J, and 8625Y in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 91795, 91809, 92128 and 92216 and prescribing of PBS items 1394J, 3162K, 8064K, 8519J, 8625Y and 11276L, along with PBS items within Anatomical Therapeutic Chemical (ATC) groups N06AB and N06AX. The Director had no persisting concerns relating to MBS item 91795.  In relation the remaining items, the Director had persisting concerns that:

• some telehealth services were rendered and prescriptions written when the practitioner was overseas and not able to bill under the MBS or prescribe under the PBS
• PBS restrictions were not complied with in all instances
• MBS requirements were not always met, including minimum time requirements where relevant
• The practitioner did not always provide sufficient clinical input. For example the records for prescribing did not reflect appropriate evaluation of the condition of the patient, or advice to the patient in regards to the management and treatment of their condition

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 91809, 92128 and 92216, and prescribing of PBS items 1394J, 3162K, 8064K, 8519J, 8625Y and 11276L and PBS medications in ATC groups N06AB and N06AX. The practitioner agreed to repay $55,000, to be disqualified from MBS items 91809, 91890, 91891, 92128 and 92216 for a period of 12 months, to be disqualified from prescribing on the PBS for four months, and will be reprimanded by the Director. The disqualification from MBS items 91890 and 91891 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a radiologist

During the review period, the practitioner rendered MBS items 56412, 56623, 56625 and 57007 at significantly higher number than most other radiologists. The Director reviewed this practitioner’s rendering of MBS items 56412, 56623, 56625, 57007, 61523, 61541 and 61553. The Director had no persisting concerns in relation to MBS items 61541 and 61553.  In relation to the remaining items, the Director had persisting concerns that:

• CT scans were performed with PET scans and co-billed where CT scans were not requested or clinically indicated
• MBS requirements were not always met, including in relation to eligibility of patients for services such as CT scans
• the practitioner’s records were not always adequate

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 56412, 56623, 56625, 57007 and 61523. The practitioner agreed to repay $400,000 and will be reprimanded by the Director.

An agreement with an orthopaedic surgeon

During the review period, the practitioner rendered MBS items 104, 105, 18272, 49809, 50103 and 91833 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 18272, 47969, 48403, 49703, 49709, 49809, 49837, 49851, 50103 and 91833. The Director had no persisting concerns in relation to MBS items 104, 18272, 48403 and 49837.  In relation to the remaining items, the Director had persisting concerns that:

• MBS requirements were not always met.  For example, some consultations occurred within a post-operative period and may be considered aftercare, and therefore not eligible to be billed as a professional attendance item
• the practitioner billed recurrent combinations of multiple MBS items which may have been more appropriately billed as a single procedure
• the practitioner’s records were not adequate.  For example, for some services there is no record of a consultation or a letter back to the referring practitioner, and consent and procedures performed were poorly documented 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 105, 47969, 49703, 49709, 49809, 49851, 50103 and 91833. The practitioner agreed to repay $63,000.

An agreement with a general practitioner

During the review period, the practitioner rendered and initiated MBS items 66596, 66833, 66839, 92024 and 92025 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering and initiating of MBS items 721, 723, 732, 10997, 66596, 66833, 66839, 92024, 92025, 92028, 92069 and 92072.  The Director had no persisting concerns in relation to MBS items 66596 and 66833.  In relation to the remaining items, the Director had persisting concerns that:

• the practitioner’s clinical input was insufficient.  For example, when providing CDM services, templates were routinely used without including sufficient individualised patient information
• MBS requirements were not always met.  For example, the Team Care Arrangement records did not reflect collaboration with two health care providers
• B12 quantitation tests were not clinically indicated and were instead initiated as part of a broad spectrum testing panel.
• he practitioner’s records were not adequate. For example, records for services provided by nurses did not include more than basic observations rather than reflecting a service to assist in managing patients’ chronic conditions.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 721, 723, 732, 10997, 66839, 92024, 92025, 92028, 92029 and 92072. The practitioner agreed to repay $40,000, be disqualified from MBS items 723, 92024, 92025, 92028, 92069 and 92072 for a period of three months, and will be reprimanded by the Director. The disqualification from MBS item 92069 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered and initiated MBS items 36, 66596 and 66833 in excess of 99% of their peers, as well as rendering a volume of daily services disproportionate to their peers.  The Director reviewed this practitioner’s rendering and initiating of MBS items 23, 36, 703, 721, 723, 66596, 66833, 66839, 91809 and 91810.  The Director had no persisting concerns in relation to MBS item 703.  In relation to the remaining items, the Director had persisting concerns that:

• MBS requirements were not met, including taking an adequate patient history, performing clinical examinations where relevant, or implementing appropriate management plans
• the practitioner’s clinical input was insufficient and documentation was inadequate across the CDM services and not sufficiently individualised.  For example, the GPMP and TCA documents appear to be based on the same templates, with generic goals that were not specific to the patient.
• the practitioner’s records were inadequate.  For example, when initiating pathology services, the records do not contain any notes reflecting a consultation, or a history or examination which explained why the tests were required.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 721, 723, 66596, 91809 and 91810.  The practitioner agreed to repay $150,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 707, 721, 723, 732 and 2195 in excess of 99% of their peers, as well as rendering a volume of daily services disproportionate to their peers.  The Director reviewed this practitioner’s rendering of MBS items 23, 36, 699, 707, 721, 723, 732, 2195, 10997, 92068, 92069 and 92072.  The Director had no persisting concerns in relation to MBS item 23.  In relation to the remaining items, the Director had persisting concerns that:

• the MBS requirements were not met, including minimum  time requirements where relevant and the collection of r information required
• the practitioner’s clinical input was not always adequate.  For example, when conducting health assessments, relevant documentation did not reflect a comprehensive history, evidence of an examination or a comprehensive management plan
• the practitioner’s record keeping was inadequate. For example, history and examination was not being recorded and the clinical indication for investigations was not clear.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 699, 707, 721, 723, 732, 2195, 10997, 92068, 62069 and 92072.  The practitioner agreed to repay $300,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 705, 2713 and 2717 in excess of 99% of their peers, as well as rendering a volume of daily services disproportionate to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 705, 721, 723, 2713, 2717 and 5020.  The Director also reviewed this practitioner’s prescribing of PBS items 1215Y and 3162K.  The Director had persisting concerns that:

• the practitioner’s records were inadequate.  For example, the clinical notes were brief and relied on the use of hot keys and templates, resulting in a lack of clear and patient specific clinical detail
• Patients may not have been present when the practitioner billed a personal consultation
• the practitioner’s clinical input was inadequate.
• PBS items were prescribed without proper consideration of the interactions with other medications being taken by the patient

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 44, 705, 721, 723, 2713, 2717 and 5020, and PBS items 1215Y and 3162K.  The practitioner agreed to repay $385,000, be disqualified from MBS items 44, 705, 721, 2717, 91802, 91811, 92024, 92068, 92117 and 92129 for a period of six months, be disqualified from MBS items 2713, 92115 and 92127 for a period of three months, and will be reprimanded by the Director. The disqualification from MBS items 91802, 91811, 92024, 92068, 92117, 92115, 92127 and 92129 reflects disqualification from equivalent telehealth items where applicable.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 723, 732 and 707 in excess of 98% of their peers, as well as rendering a volume of daily services disproportionate to peers.  The Director reviewed this practitioner’s rendering of MBS items 23, 36, 707, 721, 723, 732, 10997 and 91809.  The Director had no persisting concerns in relation to MBS items 23 and 91809.  In relation to the remaining items, the Director had persisting concerns that:

• the MBS requirements were not met, including minimum consultation time requirements where relevant and the collection of r information required
• CDM services were not always clinically indicated and were not individualised to the patient’s specific care needs
• 10997 services provided were not consistent with there being an existing GPMP or TCA

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 707, 721, 723 and 732.  The practitioner agreed to repay $99,000, and will be reprimanded by the Director.

B. PSR Committee final determinations

One final determination came into effect in October 2022:

PSRC 1151

On 5 October 2022 a final determination came into effect regarding a midwife.  The midwife was directed to:

• be reprimanded
• be counselled
• repay the amount of $50,000 to the Commonwealth.

These directions followed from a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with services rendered as MBS items 82110, 82115, 82135 and 82140.

In relation to the pre-natal attendance services (MBS items 82110 and 82115) the Committee made findings on the basis of one or more of the following:

• The clinical content recorded was insufficient to justify an attendance of at least 40 or 90 minutes, respectively
• Some long attendances were not clinically indicated, having regard to the frequency of attendances on patients and that some were also receiving antenatal care from other providers
• For MBS item 82115, the records did not support that a maternity care plan was provided including the level of clinical detail that would be expected by the general body of midwives
• The clinical records were inadequate and in some parts not contemporaneous

In relation to the postnatal attendance services (MBS items 82135 and 82140) the Committee made findings on the basis of one or more of the following:

• Some long attendances were not clinically indicated, having regard to the frequency of attendances on patients and that some were also receiving antenatal care from other providers
• The midwife billed the services outside the post-natal time period required by the MBS (with the patient’s baby aged more than seven weeks)
• For MBS item 82140, there was not a comprehensive examination of the mother and the baby, as required by the MBS.
• The clinical records were inadequate and in some parts not contemporaneous

C. Federal Court

No decisions concerning PSR were handed down in October 2022

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

No matters were referred to the major non-compliance (fraud) division in October 2022.

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in October 2022.