PSR Director's update for September 2023

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

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

An agreement with an orthopaedic surgeon

During the review period, the practitioner rendered MBS items 49321, 49509, 49521, and other items in excess of 99% of their peers, and the Director reviewed the practitioner’s rendering of those items. The Director had persisting concerns that:

• MBS requirements were not always met. For example, it was not clear from the reviewed records that the practitioner always performed major bone grafting as required when providing MBS items 49321 and 49521
• the practitioner did not always provide adequate clinical input, including to justify the co-billing of other services in association with procedural items
• not all services rendered by the practitioner were clinically indicated, including major bone grafting surgeries
• the practitioner’s record keeping was inadequate. For example, the notes often consisted of auto-generated text and did not contain sufficient detail to explain the clinical indication for services.

The practitioner acknowledged having engaged in inappropriate practice in connection with all items reviewed by the Director. The practitioner agreed to repay $233,000, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 721, 723, 732 and 10660 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 10660, 66596, 66695, 66833, 66838, 93624 and 93634, and had no persisting concerns in relation to MBS item 66833. 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 initiated pathology services that were not clinically indicated
• the practitioner did not always provide adequate clinical input to all services, including for chronic disease management (CDM) services
• the practitioner’s record keeping was inadequate. The practitioner’s records often consisted of template or hotkey text with minimal personalisation, and some records were identical over multiple consultations and across multiple patient records.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 721, 723, 732, 10660, 66596, 66695, 66838, 93624 and 93634. The practitioner agreed to repay $381,500, to be disqualified from providing MBS item 36 and 91810 services for 6 months, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025 and 92028 services for 9 months, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 11707, 30029, 30061, 30064, 30219, 31364, 91809 and 91891 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 5020, 5040, 11707, 30029, 30061, 30064, 30071, 30219, 31363, 31364, 91809 and 91891, and had no persisting concerns in relation to MBS items 30071 and 30219. The Director had persisting concerns in relation to the remaining items that:

• the practitioner’s record keeping was inadequate. For example, the records often lacked sufficient clinical information including relevant patient history and explaining the reason for therapeutic procedures and referrals
• MBS requirements were not always met. For example, some of the practitioner’s MBS item 31363 and 31364 services involved excisions smaller than required by the MBS descriptor for those items and, when providing level B and C attendance items, the practitioner did not always perform specified tasks in the MBS item descriptors when these would have been clinically relevant
• when patients had multiple lesions requiring excision, the practitioner appeared to excise these at separate attendances without a clear clinical reason for doing so.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 5020, 5040, 11707, 30029, 30061, 30064, 31363, 31364, 91809 and 91891. The practitioner agreed to repay $455,000, to be disqualified from providing MBS item 36 and 91801 services for 6 months, to be disqualified from providing MBS item 30064 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 31362, 31364, 31366, 45201 and 45203 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 31362, 31364, 31366, 45201 and 45451. The Director had persisting concerns that:

• MBS requirements were not always met when the practitioner billed MBS item 31362, 31364 or 31368 therapeutic procedures for skin harvesting concurrently with MBS 45451, which itself includes skin harvesting
• not all therapeutic procedures performed by the practitioner may have been clinically indicated. For example, it was often not clear from the reviewed records why a skin flap or skin graft was used rather than a less invasive method of repair
• the practitioner’s record-keeping was inadequate. There were not always records for the date of service, and when records were contemporaneous, they were not sufficiently comprehensible to allow another practitioner to assume care of the patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 31362, 31364, 31366, 45201 and 45451. The practitioner agreed to repay $152,500, to be disqualified from providing MBS item 31362 and 31364 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 item 721 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 5049, 5063, 5067 and 30192, and had no persisting concerns in relation to MBS item 30192.  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 adequate clinical input
• the practitioner’s record-keeping was inadequate. There were not always records for the date of service, and where contemporaneous records were identified they were often brief, difficult to understand, and lacking in essential details.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 721, 723, 5049, 5063 and 5067. The practitioner agreed to repay $200,000, to be disqualified from providing MBS item 721, 723, 5049, 5063, 5067, 92024 and 92025 services for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered total MBS services disproportionately to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 900, 2713, 66596, 66719, 66819 and 91809. The Director had persisting concerns that:

• MBS requirements were not always met. For example, eligibility criteria for CDM services and MBS item 900 were not met
• not all pathology services initiated by the practitioner were clinically indicated, and were often initiated for screening purposes
• the practitioner’s record keeping was inadequate. Most reviewed records contained generic text with limited or no additional information to explain what occurred during the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 721, 723, 900, 2713, 66596, 66719, 66819 and 91809. The practitioner agreed to repay $223,000, to be disqualified from providing MBS item 900, 2713, 91891, 92115 and 92127 services for 12 months, and will be counselled by the Director.

An agreement with an Other Medical Practitioner (OMP)

During the review period, the practitioner rendered MBS items 585, 731, 5028, 5049, 90043 and 90051 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 585, 5028, 5049, 90043 and 90051, and PBS items 10770W, 3132W, 8865N, 8866P and 8934F. The Director had persisting concerns that:

• MBS requirements were not always met. For example, MBS requirements regarding urgency and minimum time requirements did not appear to be met where relevant
• the practitioner’s prescribing was not always clinically indicated
• the practitioner’s record keeping was inadequate. For example, there was often no entry on the date of service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 585, 5028, 5049, 90043, 90051 and prescribing PBS Items 10770W, 3132W, 8865N, 8866P, 8934F. The practitioner agreed to repay $580,000, to be disqualified from providing MBS item 585, 5028, 5049, 90043 and 90051 services for 9 months, and will be reprimanded by the Director.

An agreement with a nuclear medicine physician

During the review period, the practitioner rendered MBS items 110 and 116 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 116. The Director had persisting concerns that the practitioner’s records were inadequate, as there were not always entries on the date of service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 116. The practitioner will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 732 and 5040 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 721, 723, 732, 5040, 5060 and 91891. 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, general practitioner management plans (GPMPs) were not comprehensive or patient specific and did not always contain relevant information regarding patients’ diagnoses
• the practitioner’s records were inadequate. In most cases, records were template-based, contained similar text across multiple patient records, and were difficult to understand.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 721, 723, 732, 5040, 5060 and 91891. The practitioner agreed to repay $375,000, to be disqualified from providing MBS item 44, 721, 723, 732, 5040, 5060, 91802, 92024, 92025, 92028 services for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered CDM review services and prescribed PBS items 01215Y, 03162K, 08455B and 02089Y in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 732, 55848 and 57341, and PBS items 1215Y, 2089Y, 3162K, 8455B and 8601Q. The Director had persisting concerns that:

• MBS requirements were not always met. For example, for CDM reviews, it was not clear that chronic conditions were reassessed, GPMPs amended, or communication carried out with collaborating providers in Team Care Arrangements where necessary
• investigations were initiated without sufficient clinical indication
• PBS requirements were not always met. For example, non-opioid analgesics were not always trialled before patients were prescribed opioids
• the practitioner’s clinical management of prescribing was inadequate. For PBS items 1215Y and 2089Y, there was no documented input regarding how to reduce dosage or warning of side effects
• the practitioner’s records were inadequate, as they did not always include a record of what occurred during consultations.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 732, 55848 and 57341 and prescribing PBS Items 1215Y, 2089Y, 3162K, 8455B and 8601Q. The practitioner agreed to repay $70,000, to be disqualified from providing MBS item 732 and 92028 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 44, 723, 732, 2713, 2717 and 92127 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 707, 721, 723, 732, 2713 and 2717. The Director had persisting concerns that:

• MBS requirements were not always met, including time requirements where relevant
• the practitioner did not always provide adequate clinical input. For example, some GPMPs were identical to those produced for the same patient 12 months earlier, where updates were clinically indicated
• the practitioner’s records were inadequate, as they often consisted of only a few words and lacked a recorded history, examination or management plan.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 36, 44, 707, 721, 723, 732, 2713 and 2717. The practitioner agreed to repay $275,000, to be disqualified from providing MBS item 36, 44, 721, 723, 732, 2713, 2717, 91801, 91802, 92024, 92025, 92028, 92115, 92117 and 92127 services for 3 months, and will be counselled by the Director.

B. PSR Committee final determinations

PSR Committee 1328

On 1 September 2023 a final determination came into effect regarding a dental practitioner. The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $133,399.03 to the Commonwealth, in respect of Child Dental Benefit Scheme (CDBS) item 88111 and 88121 services in connection with which the practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee.

In relation to the CDBS item 88111 services the Committee made findings on the basis of one or more of the following:

• There was no clinical indication for the removal of plaque. The service was not a clinically relevant service, as removal of plaque was not necessary for the patient’s appropriate care or treatment.
• The documented clinical findings in relation to presence of plaque were ambiguous and unreliable and/or the clinical record was inadequate in that the method and extent of plaque removal was not specified and/or the clinical record was wholly insufficient to substantiate the service, as there was no clinical entry for the date of the service.
• Use of a prophy cup, where used, was not clinically indicated because of the risk that this noisy, invasive procedure, would do more harm than good and would be likely to scare the child.
• CDBS item requirements were not met, in that:
  • the practitioner did not remove plaque and/or stain from the surfaces of all teeth, and/or
  • very young children may not have been sufficiently cooperative to enable plaque to be removed ‘from the surfaces of all teeth,’ and/or
  • for a limited number of services, the service was provided by a dentist other than the practitioner.
• There was no record of informed financial consent for the service.

In relation to the CDBS item 88121 services the Committee made findings on the basis of one or more of the following:

• The application of a remineralising agent was not clinically indicated. The record does not reflect that there was demineralisation, hypomineralisation or caries. The service was not a clinically relevant service as the application of a remineralising agent was not necessary for the child’s appropriate care or treatment.
• The Committee did not accept that use of MBS item 88121 as a preventive measure having regard to the existence of plaque is supported by the CDBS or that it would be conduct acceptable to the general body of dental practitioners.
• The Committee did not accept that a patient of the relevant age would have been sufficiently cooperative to enable the adequate application of a demineralisation agent, noting that Tooth Mousse needs to be left undisturbed in the mouth for several minutes to be effective. If the patient is not cooperative to the extent that the service cannot be completely performed, the item cannot be claimed.
• The CDBS requirements were not met in that the services were provided by a dentist other than the practitioner.
• There was no record of informed financial consent for the service.
• The clinical record was inadequate, in that there was:
  • no record of whether or not the child had an intolerance or allergy to dairy, presenting a risk to the child, and/or
  • no record of the particular remineralisation agent used, and/or
  • no record of the technical method of application used.
• In the circumstances of the record reflecting the child was not willing to have their teeth cleaned, the application of a remineralisation agent was not clinically indicated as it would not have been effective on unclean teeth.

C. Federal Court

No final decisions concerning PSR were handed down in September 2023.

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

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

E. Referrals to AHPRA (106XA/B)

1 matter was referred to AHPRA in September 2023.