PSR Director's update for August 2023

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

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

An agreement with a general practitioner

During the review period, the practitioner provided MBS item 36 and PBS items 3162K, 1215Y, 8254K and 2089Y in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 585, 721, 723, 5020, 5040, 91809, 91810, 93624 and 93634, and prescribing of PBS items 1215Y, 2089Y, 2355Y, 3162K and 8254K, and had no persisting concerns in relation to MBS items 93624 and 93634. 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. The practitioner’s records were often brief and did not always contain relevant details to explain the service
• the practitioner’s clinical input was not always sufficient, including the prescription of multiple benzodiazepines without documenting discussions with the patient about the risk of polypharmacy
• PBS restrictions were not always met.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 585, 721, 723, 5020, 5040, 91809 and 91810 and prescribing PBS items 1215Y, 2089Y, 2355Y, 3162K and 8254K. The practitioner agreed to repay $400,000, to be disqualified from providing MBS item 721, 723, 92024 and 92025 services for 12 months, to be disqualified from providing MBS item 36 and 5040 services for 6 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS items 585, 591, 594 and 599 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 585, 591, 594 and 599.

The Director had persisting concerns that MBS requirements were not always met. For example, it was not clear that an urgent assessment was required and/or whether the consultations were requested in the same unbroken after-hours period as the services provided.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 585, 591, 594 and 599. The practitioner agreed to repay $560,000, to be disqualified from providing MBS item 585 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, 732, 10997, 11610, 92024, 92025 and 92028 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 732, 10997, 11610, 92024, 92025, 92028 and 92072, and had no persisting concerns in relation to MBS items 721 and 92024. The Director had persisting concerns in relation to the remaining items that:

• it was not always clear that patients were eligible for chronic disease management (CDM) services provided by the practitioner, including where CDM reviews were of plans prepared by another practitioner
• the practitioner’s record keeping was inadequate. For example, records for some MBS item 11610 services did not document relevant history or examination findings.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 723, 732, 10997, 11610, 92025, 92028 and 92072. The practitioner agreed to repay $57,000, to be disqualified from providing MBS item 10997 and 92072 services for 12 months, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner provided MBS items 721 and 723 and PBS items 1215Y and 2622B in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 92068 and 92069, and prescribing of PBS items 1215Y, 2622B and 3162K, and had no persisting concerns in relation to PBS items 1215Y and 2622B. The Director had persisting concerns in relation to the remaining items that:

• MBS requirements were not always met. For example, it was not clear that the practitioner had collaborated with other healthcare providers when making team care arrangements (TCAs)
• the practitioner did not always provide sufficient clinical input. For example, many of the reviewed services did not contain individualised goals to assist patients in managing their chronic conditions
• not all services rendered by the practitioner were clinically indicated. For example, there was sometimes no clinical indication that patients required a GPMP or TCA for managing their condition
• the practitioner’s record keeping was inadequate. The reviewed records often consisted of template text which was not sufficiently individualised for the patient and included irrelevant information.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 721, 723, 92068 and 92069 and prescribing PBS item 3162K. The practitioner agreed to repay $270,000, to be disqualified from providing MBS item 721, 723, 92024 and 92025 services for 12 months, and will be reprimanded and counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 721, 723, 732 and 10997 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 2713, 5040, 10997 and 92072. The Director had persisting concerns that:

• MBS requirements were not always met including minimum time requirements where relevant
• the practitioner did not always provide sufficient clinical input. For example, CDM documents were not sufficiently individualised  to each patient’s clinical needs
• the practitioner’s record keeping was inadequate, including because their records did not document sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 36, 721, 723, 732, 2713, 5040, 10997 and 92072. The practitioner agreed to repay $319,000, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025, 92028 and 92072 services for 10 months, and will be counselled by the Director.

An agreement with a psychiatrist

During the review period, the practitioner rendered MBS items 350, 352, 356, 357, 92499 and 92500 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 296, 304, 350, 352, 356, 357, 91840, 92499 and 92500, and had no persisting concerns in relation to MBS items 296, 304 and 357. 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 did not always provide sufficient clinical input to appropriately manage patients’ conditions and/or to support the co‑billing of MBS item 296 in association with other services
• the practitioner’s record keeping was inadequate. For example, some of the reviewed records were difficult to understand and/or did not contain sufficient detail to adequately explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 350, 352, 356, 91840, 92499 and 92500. The practitioner agreed to repay $166,000 and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner provided MBS items 721, 723, 2712, 2717, 5020, 66650, 66716, 66833, 69396 and 71097 and PBS item 8254K in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 23, 703, 721, 723, 2712, 2713, 2717, 5020, 66650, 66716, 66833, 69396, 71097 and 91806, and prescribing of PBS items 1215Y and 3162K, and had no persisting concerns in relation to MBS items 23, 2712, 66716, 66833, 69396 and 71097. The Director had persisting concerns in relation to the remaining items that:

• MBS requirements were not always met, including the eligibility requirements for health assessment services and mental health services
• the practitioner prescribed PBS items 1215Y and 3162K when it was not clinically indicated
• the practitioner’s record keeping was inadequate, and entries for different dates within a patient record and between different patient records were often identical making it hard to discern relevant clinical features.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS Items 703, 721, 723, 2713, 2717, 5020, 66650 and 91806 and prescribing PBS Items 1215Y and 3162K. The practitioner agreed to repay $611,000, to be disqualified from providing MBS item 2713, 92115 and 92127 services for 36 months, to be disqualified from providing MBS item 703, 721, 723, 2717, 91806, 92024, 92025 and 92117 services 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 721 and 723 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 732, 92068, 92069 and 92072. The Director had persisting concerns that:

• MBS requirements were not always met. For example, it was not clear from the reviewed records that there was two-way communication with other practitioners when providing MBS item 723 services
• CDM services provided by the practitioner were not always clinically relevant. For example, some patients appeared to present with acute, rather than chronic, conditions
• it was not clear that the practitioner provided sufficient clinical input into each CDM service
• the practitioner’s record keeping was inadequate. For example, their reviewed records were often generic and failed to record consultations or patient plans and outcomes in sufficient detail to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 721, 723, 732, 92068, 92069 and 92072. The practitioner agreed to repay $100,000, to be disqualified from providing MBS item 92024, 92025 and 92028 services for 12 months, and will be counselled by the Director.

An agreement with a psychiatrist

During the review period, the practitioner rendered MBS item 297, 324, 326, 348, 861 and 92458 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 297, 324, 326, 348, 861 and 92458. The Director had persisting concerns that:

• MBS requirements were not always met  including minimum time requirements where relevant
• it was not clear that the practitioner provided sufficient clinical input. For example, history and examination were often not evident
• the practitioner’s record keeping was inadequate. For example, in some cases, records could not be found for the date of service and when records were found they often contained insufficient information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 297, 324, 326, 348, 861 and 92458. The practitioner agreed to repay $246,000, and to be disqualified from providing MBS item 348 and 861 services for 9 months, and will be counselled by the Director.

An agreement with a cardiologist

During the review period, the practitioner rendered MBS items 132, 133 and 92432 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 132, 133 and 92432. The Director had persisting concerns that:

• MBS requirements were not always met including subsequent-billing restrictions and minimum time requirements where relevant
• it was not always clear that the practitioner provided sufficient clinical input. For example, there was often little evidence that an adequate assessment occurred
• the practitioner’s record keeping was inadequate. For example, there were often no records of attendances.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 132, 133 and 92432. The practitioner agreed to repay $50,000, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner provided MBS items 3, 2713 and 91890 in excess of 99% of their peers and rendered a prescribed pattern of services (the 80/20 rule). The Director reviewed this practitioner’s rendering of MBS items 3, 2713 and 91890, and provision of a prescribed pattern of services. The Director had no concerns in relation to MBS items 3 and 91890, and formed the view that a Committee would conclude that exceptional circumstances existed that affected the rendering of services on each of the days in the prescribed pattern of services.

In relation to MBS item 2713, the Director had persisting concerns that:

• MBS requirements were not always met including minimum time requirements. The practitioner did not provide sufficient clinical input. For example, the practitioner did not always record an examination of a patient’s mental state where it was clinically indicated
• the practitioner’s record keeping was inadequate. The records were generally brief and did not always include sufficient history concerning the patient’s condition or to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 2713. The practitioner agreed to repay $9,500, and be counselled by the Director.

B. PSR Committee final determinations

On 14 August 2023 a final determination came into effect regarding a chiropractor. The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $25,000 to the Commonwealth, in respect of MBS items 10964, 57712, 57715 and 58121 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 item 10964 for a period of 3 months and MBS items 57712, 57715 and 58121 for a period of 9 months.

In relation to the MBS item 10964 services the Committee made findings on the basis that the practitioner did not provide services but instead allowed their provider number to be incorrectly attributed to services which were rendered by another practitioner in the practice. 

In relation to the MBS item 57712, 57715 and 58121 services the Committee made findings on the basis of one or more of the following:

• there was no clinical indication for initiating an x-ray of the hips or pelvis alone or in a series of x-rays with the spine or, if there was a clinical indication at the date of the service, the record was insufficient in clinical information to support the request
• an x-ray of the hips or pelvis alone or in a series of x-rays with the spine was ordered without an adequate rationale as to whether each x‑ray was clinically indicated.

C. Federal Court

No final decisions concerning PSR were handed down in August 2023

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

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

E. Referrals to Ahpra (106XA/B)

One matter was referred to Ahpra in August 2023.