PSR Director's update for May 2023

Published date

19 June 2023

A. Director’s Section 92 agreements effective in May 2023

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

An agreement with a medical practitioner

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 36, 721, 723, 732, 2525, 2701 and 92071 in excess of 99% of their peers, and initiated MBS items 66596, 66839 and 66833 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 721, 723, 732, 10997, 66596, 66833 and 66839. The Director had persisting concerns that:

MBS requirements, including minimum time requirements where relevant, were not always met
the practitioner did not provide sufficient clinical input for some services including where the service was provided by a nurse without involvement by the practitioner
there was often no apparent clinical indication for MBS item 66596, 66833 and 66839 services initiated by the practitioner
the practitioner’s record-keeping was inadequate. For example, some chronic disease management documents were unable to be located, and others were insufficiently personalised to explain the service provided.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 44, 721, 723, 732, 10997, 66596, 66833 and 66839. The practitioner agreed to repay $351,000, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025 and 92028 services for 10 months, and will be reprimanded and counselled by the Director.

An agreement with a cardiologist

During the review period, the practitioner rendered MBS items 132 and 133 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 55116, 55126 and 55141, and had no persisting concerns in relation to MBS items 55116. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not met. For example, for MBS items 110 and 116, a number of services appeared to be for a review consultation or for monitoring an existing condition rather than for an initial attendance in a single course of treatment
the initiating of MBS items 55126 and 55141 was not always clinically indicated and appeared to be for routine monitoring
the practitioner inappropriately co-billed a professional attendance item with item 55141 when there was no recorded clinical input by the practitioner justifying the attendance.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 110, 116, 132, 133, 55126 and 55141. The practitioner agreed to repay $750,000, to be disqualified from providing MBS item 132, 133, 92422 and 92423 services for 18 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 30071, 30192, 45665, 45201 and 45451 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 5020, 18236, 30071, 30192, 30196, 31358, 31361, 31363, 45201, 45451, 45665 and 91809, and had no persisting concerns in relation to MBS items 18236, 30071, 30192, 30196, 45201, 45451 and 45665. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met. For example, it was not always clear that a patient history was taken for MBS item 23 services where clinically necessary or whether MBS 5020 services were provided in the after-hours period
the practitioner did not always provide adequate clinical input. For example, it was not always clear whether non-surgical options were considered and discussed
the practitioner’s record-keeping was inadequate. For example, it was not always clear how many lesions were removed for each patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 5020, 31358, 31361, 31363 and 91809. The practitioner agreed to repay $108,000 and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 699, 2713, 11700, 11707, 31356, 31357, 31360, 31361, 31362, 31365, 31366, 31372, 31374 and 92127 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 699, 707, 721, 723, 732, 2713, 5040, 11700, 11707, 31361, 31362, 91810 and 92127. The Director had persisting concerns that:

MBS requirements were not always met, including minimum time requirements for services billed as MBS items 36, 699, 707, 2713, 5040, 91810 and 92127
the practitioner routinely billed multiple MBS items for attendances in circumstances where the requirements for each item billed were not separately met
the practitioner’s record keeping was inadequate. For example, the practitioner appeared to rely on templates when providing health assessment services and these were not sufficiently individualised to the patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 699, 707, 721, 723, 732, 2713, 5040, 11707, 31361, 31362, 91810 and 92127. The practitioner agreed to repay $330,000, to be disqualified from providing MBS item 699, 732, 2713, 92028, 92115 and 92127 services for 12 months, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721,723, 5028, 10997 and 91809 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 599, 721, 723, 732, 2715, 5020, 5028, 10997, 91809 and 91810, and had no persisting concerns in relation to MBS items 36, 599, 5020 and 91809. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met, including minimum time requirements where relevant
chronic disease management and mental health treatment plans were template based, lacking sufficient individualisation and contained generic goals and actions which were not always relevant to patients’ needs
the practitioner’s record-keeping was inadequate, often with minimal history and insufficient information to explain what occurred during the attendance.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 721, 723, 732, 2715, 5028, 10997 and 91810. The practitioner agreed to repay $284,000, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025 and 92028 services for 12 months, to be disqualified from providing MBS item 10997 services for 3 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

PSRC 1015

On 2 May 2023 a final determination came into effect regarding a respiratory and sleep medicine physician. The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $1,959,718.75 to the Commonwealth, which represented total of the benefits paid in respect of MBS item 12250 in connection with which the practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee
be disqualified from rendering MBS item services 12250 for a period of 12 months.

In relation to the MBS item 12250 services the Committee made findings on the basis of one or more of the following:

The regulatory requirements for billing an MBS item 12250 service were not met, including that the service was largely performed prior to any knowledge or input on the part of the practitioner.
The practitioner failed to adequately supervise the technician and/or scorer in relation to the service.
The practitioner’s clinical input in to the service was inadequate.
The medical record was inadequate and the practitioner failed to meet other legislative requirements.

C. No further action decisions

In May 2023, the Director made the decision to take no further action in connection with five reviews.

Request to review a general practitioner

The practitioner rendered attendance items and therapeutic procedures in excess of their peers. The Director reviewed a random sample of services rendered as MBS items 36, 30071, 30192, 30196, 31358, 3136, 31363, 31373, 31376 and 45201. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

Request to review a general practitioner

The practitioner rendered a prescribed pattern of services (more than 80 professional attendances on more than 20 days in a 12-month period). The Director reviewed a random sample of services rendered as MBS items 3 and 5000. The Director was satisfied that a Committee would find exceptional circumstances (relating to the COVID-19 pandemic) existed that affected the rendering of the services, and that there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

Request to review a general practitioner

The practitioner rendered a prescribed pattern of services (more than 80 professional attendances on more than 20 days in a 12-month period). The Director reviewed a random sample of services rendered as MBS item 3 and was satisfied that a Committee would find exceptional circumstances (relating to the COVID-19 pandemic) existed that affected the rendering of the services, and that there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

Request to review a pathologist

The practitioner rendered a prescribed pattern of services (more than 80 professional attendances on more than 20 days in a 12-month period). The Director reviewed a random sample of services rendered as MBS items 52 and 5100. The Director was satisfied that a Committee would find exceptional circumstances (relating to the COVID-19 pandemic) existed that affected the rendering of the services, and there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

Request to review a general practitioner

The practitioner rendered a prescribed pattern of services (more than 80 professional attendances on more than 20 days in a 12-month period). The Director reviewed a random sample of services rendered as MBS item 3 and was satisfied that a Committee would find exceptional circumstances (relating to the COVID-19 pandemic) existed that affected the rendering of the services, and there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

D. Federal Court

No decisions concerning PSR were handed down in February 2023.

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

No matters were referred to the major non-compliance (fraud) division in May 2023.

F. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in May 2023.