PSR Director's update for January 2024

A. Director’s Section 92 agreements effective in January 2024

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

An agreement with a vascular surgeon

During the review period, the practitioner rendered MBS item 11602 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 11602, 55054, 55246, 60033, 60066 and 60069. During the course of reviewing those items, MBS item 32523, 32526 and 60078 services were also reviewed. The Director had persisting concerns that:

• MBS requirements were not always met. For example, not all services rendered were ‘complete’ services and two MBS items were billed without rendering two distinct services
• the practitioner’s record keeping was inadequate. In some instances, records for claimed services could not be located. Imaging results were similarly not present for all reviewed services
• not all services rendered by the practitioner during the review period were clinically indicated. For example, services with higher imaging runs were frequently claimed after previous ultrasounds had been performed.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 11602, 32523, 32526, 55054, 55246, 60033, 60066, 60069 and 60078. The practitioner agreed to repay $310,000, to be disqualified from providing MBS item 60033, 60066 and 60069 services for 9 months, and will be counselled by the Director.

An agreement with a general 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 110 and 116, and had no concerns in relation to MBS item 110. The Director had persisting concerns that the practitioner’s records were inadequate. In some instances, no records could be located for rendered services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 116. The practitioner agreed to repay $2,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered the highest number of MBS item 5028 services in Australia. The Director reviewed this practitioner’s rendering of MBS items 903, 5028 and 91891, and PBS items 2622B, 3132W, 8456C and 8866P, and had no concerns in relation to MBS items 903 and 91891. The Director had persisting concerns in relation to the remaining items that:

• MBS requirements were not always met for MBS item 5028 services. It was not always clear whether the practitioner personally attended patients
• the practitioner’s record keeping was inadequate. When records were present, they were brief and did not contain sufficient detail to explain what occurred during services
• the practitioner’s clinical management in connection with prescribing PBS items 2622B, 3132W, 8456C and 8866P was insufficient. For example, the practitioner did not always review the clinical indication for ongoing prescribing.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 5028 and prescribing PBS items 2622B, 3132W, 8456C and 8866P. The practitioner agreed to repay $190,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 36, 91809 and 91891 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 2712, 2715, 10997, 91809, 91891, 92114 and 92126. The Director had persisting concerns that:

• MBS requirements were not always met. For example, MBS item 91809 services were rendered for straightforward, non-complex presentations
• the practitioner’s record keeping was inadequate. The reviewed records were often brief, and often lacked individualisation to the patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 721, 723, 732, 2712, 2715, 10997, 91809, 91891, 92114 and 92126. The practitioner agreed to repay $290,000, to be disqualified from providing MBS item 2712, 92114 and 92126 services for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered more total services than 99% of their peers and prescribed PBS items 1215Y, 2622B, 3162K, 2089Y, 8254K and 2335X in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 66596, 66833 and 91890, and prescribing of PBS items 1215Y, 2089Y, 2335X, 2622B, 3162K and 8254K. The Director had persisting concerns that:

• MBS requirements were not always met, including recording patient histories when required
• not all MBS item 66596 and 66833 services were clinically indicated
• the practitioner’s record keeping was inadequate. The reviewed records were often very brief, and failed to include relevant information
• medications were not always clinically indicated and the practitioner did not always provide appropriate long-term clinical management.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 66596, 66833, 91890 and prescribing PBS Items 1215Y, 2089Y, 2335X, 2622B, 3162K and 8254K. The practitioner agreed to repay $235,000, to be disqualified from providing MBS item 91790 and 91890 services for
9 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723, 732, 92027 and 92028 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 732, 92028 and 92734. The Director had persisting concerns that:

• MBS requirements were not always met. For example, the practitioner’s Chronic Disease Management (CDM) plans were sometimes prepared for patients who did not have a chronic or terminal disease
• the practitioner’s record keeping was inadequate. For example, CDM documentation was heavily template-based, and did not include meaningful goals.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 721, 723, 732, 92028 and 92734. The practitioner agreed to repay $295,000, to be disqualified from providing MBS item 723, 732, 92025, 92028, 92718 and 92734 services for 6 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

No final determinations came into effect in January 2024.

C. Federal Court

No final decisions concerning PSR were handed down in January 2024.

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

0 matters were referred to the major non-compliance (fraud) division in January 2024.

E. Referrals to AHPRA (106XA/B)

0 matters were referred to AHPRA in January 2024.