PSR Director's update for June 2023

Published date

28 July 2023

Last updated

28 July 2023

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

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

An agreement with a general practitioner

During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 160, 5028, 5049, 5067, 90035, 90043 and 90051 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 160, 5028, 5049, 5067, 18236, 31363, 45202, 90035, 90043 and 90051, and prescribing of Pharmaceutical Benefits Scheme (PBS) items 1215Y, 2089Y, 2622B, 3132W, 8513C and 9365X, and had no persisting concerns in relation to the PBS items reviewed. The Director had persisting concerns in relation to the MBS items that:

MBS requirements were not always met, including minimum time requirements for services billed as MBS items 160, 5028, 5049, 5067, 90035, 90043 and 90051
MBS item 18236 services were not always clinically indicated
the practitioner’s record keeping was inadequate. For example, there was not always an entry for services in the record, and records often failed to include prescriptions and correspondence.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 160, 5028, 5049, 5067, 18236, 31363, 45202, 90035, 90043 and 90051. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 160 services for 12 months, to be disqualified from providing MBS item 5067 and 90051 services for 9 months, and will be counselled by the Director.

An agreement with a nurse practitioner

During the review period, the practitioner rendered MBS item 82205 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 82205. The Director had persisting concerns that:

MBS requirements were not always met
the practitioner did not always provide adequate clinical input. For example, it was not always clear that vaccination pre-screening forms were completed or considered
the practitioner did not always obtain informed consent for vaccinations
the practitioner’s record keeping was not always contemporaneous and adequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Item 82205. The practitioner agreed to repay $56,000, to be disqualified from providing MBS item 82205 services for 3 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 721, 723, 732 and 92072 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 721, 723, 732, 2713, 2715, 91809, 91810, 92068, 92069 and 92072. The Director had persisting concerns that:

MBS requirements were not always met. For example, minimum time requirements for MBS item 36 and 91810 services
chronic disease management (CDM) services were not always clinically indicated
the practitioner’s record keeping was inadequate. For example, there was often no record of history, examination or communication of test results to patients.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 44, 721, 723, 732, 2713, 2715, 91809, 91810, 92068, 92069 and 92072. The practitioner agreed to repay $550,000, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025 and 92028 services for 36 months, to be disqualified from providing MBS item 91890 and 91891 services for 18 months, to be disqualified from providing MBS item 2713, 2715, 92115, 92116 and 92127 services for 6 months, and will be reprimanded and counselled by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS items 54 and 91814 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 53, 54, 229, 230, 233, 5040 and 91814. The Director had persisting concerns that:

MBS requirements were not always met including minimum time requirements where relevant
the practitioner’s record keeping was inadequate. For example, records did not always include sufficient information to enable another practitioner to effectively undertake ongoing care of patients
the practitioner’s clinical input was often insufficient, with no clear documented history examination or management recorded
CDM services rendered were not always clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 53, 54, 229, 230, 233, 5040, 91814. The practitioner agreed to repay $380,000, and will be reprimanded and counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 723, 732, 10660, 93624 and 93634 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 5020, 5040, 10660, 10997, 91809, 91891, 93624 and 93634, and had no persisting concerns in relation to MBS items 5020, 91891 and 93624. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met, including minimum time requirements where relevant
the practitioner’s record-keeping was inadequate. For example, records were overly reliant on templates and ‘hotkeys’ without appropriate personalisation and did not always explain the service that was rendered
the practitioner did not always provide sufficient clinical input, including not addressing all of the patient’s conditions and providing sufficient clinical input into CDM review services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 721, 723, 732, 5040, 10660, 10997, 91809 and 93634. The practitioner agreed to repay $240,000, to be disqualified from providing MBS item 732 and 92028 services for 5 years, to be disqualified from providing MBS item 721, 723, 92024 and 92025 services for 12 months, and will be reprimanded by the Director.

An agreement with a chiropractor

During the review period, the practitioner initiated MBS diagnostic imaging services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 57712, 57715 and 58112. The Director had persisting concerns that:

the practitioner’s records were inadequate. For example, records were often brief and lacking in sufficient detail to explain services including as to examinations performed, management and clinical reasoning
there was not always a clear clinical indication for the diagnostic imaging services initiated or for repeating imaging
it was not always clear from the patient file that informed consent had been obtained prior to ordering diagnostic imaging.

The practitioner acknowledged having engaged in inappropriate practice in connection with the provision of MBS items 57712, 57715 and 58112. The practitioner agreed to repay $30,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 585, 594, 599, 5028, 5049 and 92216 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 585, 594, 599, 5028, 5040, 5049, 90035, 90043, 91809 and 92216, and had no persisting concerns in relation to MBS items 585, 594, 599, 5028, 90035, 90043, 91809 and 92216. The Director had persisting concerns in relation to MBS items 5040 and 5049 that:

the practitioner did not meet MBS requirements including minimum time requirements
the practitioner’s records were inadequate. For example, entries did not always provide sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 5040 and 5049. The practitioner agreed to repay $10,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 91800 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS item 91800 services and prescribing of PBS item 8254K. The Director had persisting concerns that:

MBS requirements for MBS item 91800 were not always met, including the requirements for a short patient history, arranging any necessary investigations, implementing a management plan or providing appropriate health care advice
the practitioner’s records were inadequate, as they relied on video recordings of telehealth services rather than making an adequate written record
There was not always a clinical indication when the practitioner prescribed an antibiotic
PBS restrictions were not always met when prescribing PBS item 8254K.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 91800 and prescribing PBS item 8254K. The practitioner agreed to repay $39,084 and will be counselled by the Director.

B. PSR Committee final determinations

PSRC 1076

On 29 June 2023 a final determination came into effect regarding a radiologist. The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $525,333.50 to the Commonwealth, which represented 50% of the benefits paid in respect of MBS items 104, 105 and 57341 services 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 104, 105 and 57341 services for a period of 12 months.

In relation to the MBS item 104 and 105 services the Committee made findings on the basis of one or more of the following:

the MBS requirements were not met, including that no MBS item 104 service was performed separate from the co-billed investigation service and/or the practitioner was not entitled to render MBS item 104 on the date of service
the service was not clinically relevant or medically necessary
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 18216 services the Committee made findings on the basis of one or more of the following:

the MBS requirements were not met, including that:
- an injection into the epidural space is not an ‘infusion’ for the purposes of the MBS item descriptor, and/or
- the injection was into the wrong location
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 18222 services the Committee made findings on the basis of one or more of the following: The MBS requirements were not met, including that:

there was no maintenance of regional anaesthesia or analgesia,
there was no infusion of a therapeutic substance, and/or
it was not appropriate to render MBS item 18222 when the procedure performed was an injection under ultrasound guidance.

In relation to the MBS item 57341 services the Committee made findings on the basis that in connection with rendering these services, the practitioner also billed other MBS item services (namely MBS items 18216 and 39013) without meeting the necessary requirements.

PSRC 1159

On 29 June 2023 a final determination came into effect regarding a medical practitioner. The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $517,215.96 to the Commonwealth, which represented 90% of the benefits paid in respect of MBS items 36, 44, 715, 721, 723, 732, 2717, 5040, 5060, 10997, 30064, 30185, 66716 and 66833 in connection with which the practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee
be fully disqualified from rendering MBS services for a period of 18 months.

In relation to the MBS item 36 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was insufficient clinical content to justify an attendance of at least 20 minutes’ duration and/or there was no detailed patient history
the practitioner’s clinical input into the service was insufficient
the medical record was inadequate, including the absence of clinical indication for management undertaken by the practitioner.

In relation to the MBS item 44 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including insufficient clinical input, examination and management to justify an attendance lasting at least 20 minutes
the practitioner’s clinical input into the service was insufficient
the medical record was inadequate, including due to the absence of clinical indication for management undertaken by the practitioner and the inclusion of inaccurate information.

In relation to the MBS item 715 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the record did not indicate that a health assessment occurred
the practitioner’s clinical input into the service was insufficient, inadequate or inappropriate
the medical record was otherwise inadequate, including on one occasion creating a ‘sham document’ from an earlier record for the date of service.

In relation to the MBS item 721 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the patient did not have a chronic condition for at least 6 months, the GP management plan (GPMP) document did not contain a comprehensive plan for the management of the patient’s condition(s) and/or was not adequately tailored to the patient’s circumstances, and/or there was no patient consent recorded. The Committee found consistently that the GPMP would not be of use to the patient or other practitioners
the service was not clinically indicated
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 723 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the patient was not eligible for the service, the GPMP / Team Care Arrangements (TCA) document did not contain a comprehensive plan or sufficiently individualised goals and actions, there was insufficient evidence of two-way communication with other providers, and/or the patient’s consent was not recorded. The Committee found consistently that the documents would not be of use to the patient or other practitioners
the practitioner’s clinical input into the service was insufficient
the medical record was inadequate.

In relation to the MBS item 732 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was insufficient evidence that the practitioner meaningfully reviewed the patient’s GPMP or TCA document and/or the patient’s consent was not recorded
the practitioner’s clinical input into the service was insufficient
the medical record was inadequate.

In relation to the MBS item 2717 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was no outcome tool administered, the GP Mental Health Treatment Plan failed to record any results of assessment, any needs, goals or actions as agreed with the patient and/or the patient’s consent, and/or there was insufficient clinical content recorded to justify an attendance of at least 40 minutes
the practitioner’s clinical input into the service was insufficient
the medical record was inadequate.

In relation to the MBS item 5040 and 5060 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was insufficient clinical content recorded to justify a consultation of at least 20 minutes’ and
40 minutes’ duration respectively
The practitioner’s clinical input into the service was insufficient
The medical record was inadequate.

In relation to the MBS item 10997 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the practice nurse did not provide a service that was consistent with the patient’s existing care plan, the patient was not eligible for the service, and/or the record did not reflect any input by the practice nurse on the date of service.
the medical record was inadequate.

In relation to the MBS item 30064 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that a foreign body was not removed from the subcutaneous layer and/or the MBS item was incorrectly billed
the medical record was inadequate.

In relation to the MBS item 66716 services the Committee made findings on the basis of one or more of the following:

the service was not clinically indicated
the medical record was inadequate.

In relation to the MBS item 66833 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the record did not indicate that the service was clinically indicated
the medical record was otherwise inadequate.

PSRC 1287

On 29 June 2023 a final determination came into effect regarding a medical practitioner. The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $400,000 to the Commonwealth, which represented the total of the benefits paid in respect of MBS items 36, 160, 597, 707, 721, 723, 2713, 5040 and 30023 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 160, 597, 707, 721, 723, 30023, 92024, 92025, 92115 and 92127 services for a period of 12 months and MBS item 36, 5040, 2713 and 91801 services for a period of 6 months.

In relation to the MBS item 36 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was no clinical content recorded to reflect a consultation of at least 20 minutes’ duration
the practitioner’s clinical input was inadequate
the medical record was inadequate.

In relation to the MBS item 160 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the patient was not in imminent danger of death and/or attended by the practitioner continuously for an hour
the practitioner’s clinical input into the service was inadequate and/or inappropriate
the medical record was inadequate and/or not contemporaneous.

In relation to the MBS item 597 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the record did not indicate that the patient required urgent treatment and/or the patient was not eligible for an MBS item 597 service
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate and/or not contemporaneous, including no record for the date of service at all in some instances.

In relation to the MBS item 707 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the patient was not eligible for an MBS item 707 service, there was no record of the practitioner performing a prolonged health assessment of at least 60 minutes’ duration and/or there was no comprehensive health care management plan for the patient
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 721 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the GPMP was not a comprehensive plan to manage the patient’s chronic conditions and/or the GPMP was not clinically indicated
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 723 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the patient was not eligible for an MBS item 723 service, there was no evidence of collaboration with 2 other providers and/or there was no TCA document for the date of service
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 2713 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the consultation would not have required at least 20 minutes and/or the patient was not eligible for an MBS item 2713 service
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate.

In relation to the MBS item 5040 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that there was insufficient clinical content recorded to justify a consultation of at least 20 minutes’ duration
the practitioner’s clinical input into the service was inadequate
the medical record was inadequate, including no record for the date of service at all.

In relation to the MBS item 30023 services the Committee made findings on the basis of one or more of the following:

MBS requirements were not met, including that the wound was not traumatic, deep or extensively contaminated, there was no evidence of the use of anaesthesia and/or a debridement procedure was not performed
the medical record was inadequate.

C. No further action decisions

In June 2023, the Director made the decision to take no further action in connection with one review.

Request to review a general practitioner

The practitioner rendered a prescribed pattern of services (more than 80 professional attendances on at least 20 days in a 12-month period). The Director reviewed a random sample of services rendered as MBS items 3 and 5000. After reviewing the practitioner’s records, the Director was satisfied that a Committee would find that 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.

D. Federal Court

No decisions concerning PSR were handed down in June 2023.

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

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

F. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in June 2023.