PSR Director's update for December 2023
A. Director’s Section 92 agreements effective in December 2023
Six agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in December:
An agreement with a general practitioner
During the review period, the practitioner rendered Medicare Benefits Schedule (MBS) items 703, 731, 903, 90035, 90043, 91800 and 92027 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 703, 903, 90035, 91800 and 92027, and had no persisting concerns in relation to MBS item 91800. The Director had persisting concerns in relation to the remaining items that:
- MBS requirements were not always met for MBS items 703 and 903, including the minimum time requirements
- the practitioner’s record keeping was inadequate. In some instances records for MBS item 703 and 903 services could not be located, and in other instances records did not record sufficient clinical information to explain the service
- the practitioner did not provide adequate clinical input for all services. For example, in some instances the records for MBS item 903 did not record input by the practitioner into a residential medication management review.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 703, 903, 90035 and 92027. The practitioner agreed to repay $159,000, to be disqualified from providing MBS item 903 and 92027 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 3, 5000 and 91890 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 3, 5000 and 91890, and had persisting concerns that the practitioner billed these items in circumstances where they did not attend on the patient.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 3, 5000 and 91890. The practitioner agreed to repay $860,000, to be disqualified from providing MBS item 3, 5000 and 91790 services for 6 months, and will be counselled by the Director.
An agreement with a dentist
During the review period, the practitioner rendered Child Dental Benefits Scheme (CDBS) items 88011, 88022, 88114, 88121, 88161 and 88162 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of CDBS items 88011, 88114, 88121, 88161 and 88162, and had no persisting concerns in relation to CDBS items 88011, 88114 and 88121. The Director had persisting concerns in relation to the remaining items that:
- the practitioner did not always provide adequate supervision to oral health therapists billing services under the practitioner’s provider number
- there was not always sufficient clinical indication for CDBS item 88161 and 88162 services billed under the practitioner’s provider number
- dental records were inadequate and did not contain sufficient clinical information to explain services.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering CDBS items 88161 and 88162. The practitioner agreed to repay $260,000 and will be reprimanded by the Director.
An agreement with a medical practitioner
During the review period, the practitioner rendered MBS items 23, 36, 2713, 2715 and 5040 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 2713, 2715 and 5040, and Pharmaceutical Benefits Scheme (PBS) items 1891M and 2237R, and had no concerns in relation to PBS item 2237R. The Director had persisting concerns in relation to the remaining items that:
- the practitioner’s record keeping was inadequate. The reviewed records were often heavily reliant on shortcuts and tick-box histories, which were not always applicable for particular patients or services and did not accurately reflect what occurred during services
- MBS requirements were not always met, including minimum time requirements where relevant
- PBS item 1891M was prescribed in instances when a first line antibiotic was indicated and should have been prescribed.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 2713, 2715 and 5040, and prescribing PBS item 1891M. The practitioner agreed to repay $405,000, to be disqualified from providing MBS item 2715 and 92116 services for 10 months, and will be reprimanded 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 132, 133, 11714, 55126 and 55141, and had no persisting concerns in relation to MBS items 11714 and 55126. The Director had persisting concerns in relation to the remaining items that:
- MBS requirements were not always met. For example, it did not appear that the practitioner prepared sufficiently complex management plans for MBS item 132 services
- the practitioner’s record keeping was inadequate. For example, entries did noy record sufficient clinical information to explain services including to support that the requirements for MBS items 132 and 133 were met.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 132, 133 and 55141. The practitioner agreed to repay $270,000, to be disqualified from providing MBS item 132 and 92422 services for 6 months, and will be reprimanded by the Director.
An agreement with a general practitioner
During the review period, the practitioner rendered MBS items 36, 44, 47, 721, 723, 5040, 5060, 91810, 91811 and 92746 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 37, 44, 47, 721, 723, 5040, 5060, 91810, 91811 and 92746, and had persisting concerns that:
- MBS requirements were not met, including minimum time requirements where relevant
- the practitioner did not provide sufficient clinical input for chronic disease management (CDM) services, including when records appeared to be largely template-based with minimal personalisation
- the practitioner may have billed CDM items on the day after patient attendance to avoid the prohibition on co-claiming these items with professional attendance items
- the practitioner’s record keeping was inadequate, including occasions where their records did not include sufficient detail of patient history or clinical actions taken.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 36, 37, 44, 47, 721, 723, 5040, 5060, 91810, 91811 and 92746. The practitioner agreed to repay $500,000, to be disqualified from providing MBS item 721 and 92024 services for 12 months, to be disqualified from providing MBS item 37 services for 3 months, and will be reprimanded by the Director.
B. PSR Committee final determinations
PSR Committee 1465
On 7 December a final determination came into effect regarding a nurse practitioner. The practitioner was directed to repay the amount of $50,000 to the Commonwealth, in respect of MBS item 82205, 82210 and 82215 services in connection with which the practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee.
- The clinical record was inadequate
- The record did not reflect adequate clinical input was provided in respect of the service or, in the alternative, if there was additional clinical input provided during the service the record was inadequate in failing to reflect this
- The clinical input recorded did not justify billing an MBS item 82205 service
- The practitioner provided insufficient clinical input into the service.
In relation to the MBS item 82210 services the Committee made findings based on one or more of the following:
- The clinical record was inadequate
- The MBS requirements were not met, in that the presentation did not involve clinical input requiring attendance of 20 minutes duration so as to justify the billing of an MBS item 82210 service.
In relation to the MBS item 82215 services the Committee made findings based on one or more of the following:
- The MBS requirements were not met in that the record did not reflect clinical input requiring attendance of 40 minutes duration so as to justify billing an MBS item 82215 service
- The clinical record did not adequately explain the service and clinical input that the practitioner provided
- The clinical record was otherwise inadequate.
PSR Committee 1481
On 8 December 2023 a final determination came into effect regarding a nurse practitioner. The practitioner was directed to repay the amount of $50,000 to the Commonwealth, in respect of MBS item 82210 and 82215 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 MBS item 82210 services the Committee made findings based on one or more of the following:
- The clinical record was inadequate
- The MBS requirements were not met, including because there was insufficient clinical input (whether properly recorded, or not) to justify a consultation lasting at least 20 minutes
- The practitioner’s clinical input into the service was inadequate.
In relation to the MBS item 82215 services the Committee made findings based on one or more of the following:
- The clinical record was inadequate
- The MBS requirements were not met in that the clinical content recorded for the service would not have required an attendance of at least 40 minutes, and if the practitioner did provide clinical management which would justify the time, this was not adequately recorded
- The practitioner’s clinical input into the service was inadequate.
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 December 2023.
E. Referrals to AHPRA (106XA/B)
Two matters were referred to AHPRA in December 2023.