PSR Director's update for March 2024
A. Director’s Section 92 agreements effective in March 2024
4 agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in March:
An agreement with a general surgeon
During the review period, the practitioner provided services per patient in excess of 99% of their peers, and rendered a number of MBS items in excess of 99% of peers. The Director reviewed this practitioner’s rendering of MBS items 30023, 31350, 31363, 45201 and 45203. The Director had persisting concerns that:
- the practitioner’s record keeping was inadequate. For example, notes were limited and often hard to understand and, in the case of pathology reports and operation notes, were often missing or blank
- MBS requirements were not always met including where services were provided in respect of lesions that did not meet MBS requirements
- it was not always clear that services were clinically indicated.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 30023, 31350, 31363, 45201 and 45203. The practitioner agreed to repay $168,000, to be disqualified from providing MBS item 30023 and 31350 services for 24 months, to be disqualified from providing MBS item 31363, 45201 and 45203 services for 6 months, and will be reprimanded by the Director.
An agreement with a neurologist
During the review period, the practitioner rendered MBS item 112, 116 and 11018 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 116 and 11018 and prescribing of PBS items 11237K and 11604R and had no concerns in relation to PBS item 11237K. The Director had persisting concerns in relation to the remaining items that:
- services were not always clinically indicated for MBS item 11018 or for a separate consultation under MBS item 116 where MBS item 11018 was co-billed
- Medicare had been incorrectly billed for services provided in circumstances which should not have attracted a Medicare benefit
- PBS requirements were not always met for prescribing item 11604R, including where patients were not ambulant.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 116 and 11018, and prescribing PBS item 11604R. The practitioner agreed to repay $239,000 and will be counselled by the Director.
An agreement with a general practitioner
During the review period, the practitioner rendered MBS items 23 and 5020 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 699, 5020, initiation of MBS items 66596 and 66833, and issuing PBS prescriptions for PBS item 1215Y, The Director had persisting concerns that:
- MBS requirements were not always met including minimum time requirements where relevant
- pathology services were not always clinically indicated
- the practitioner’s records were inadequate. For example, entries were brief and failed to include sufficient information to explain what occurred during consultations
- the practitioner’s prescribing did not always meet PBS requirements
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 699, 5020, initiating MBS items 66596 and 66833 and prescribing PBS item 1215Y. The practitioner agreed to repay $196,000 and will be reprimanded by the Director.
An agreement with an endocrinologist
During the review period, the practitioner rendered MBS items 132, 133 and 92431 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 132, 133, 92431 and 92432. The Director had persisting concerns that:
- MBS requirements were not always met including minimum time requirements where relevant. It was also not always clear that treatment and management plans were sufficiently complex or that patients had multiple morbidities as required
- the practitioner’s records were inadequate. For example, records contained insufficient information to explain what occurred during consultations.
The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 132, 133, 92431, and 92432. The practitioner agreed to repay $273,000, to be disqualified from providing MBS item 132 and 92422 services for 12 months and will be reprimanded by the Director.
B. No further Action Decisions
Request to review a paediatrician
During the review period, the practitioner rendered MBS item numbers 132, 133 and 92432 in excess of 99% of their peers.
The Director reviewed a random sample of services rendered MBS items 132, 133 and 92432. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.
Request to review a dentist
During the review period, the practitioner rendered CDBS items 88011, 88012, 88022, 88111, 88114, 88121, 88161, 88162 and 88587 in excess of 99% of their peers.
The Director reviewed a random sample of services rendered as CDBS items 88011, 88012, 88022, 88111, 88114, 88121, 88161, 88162 and 88587. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.
C. PSR Committee final determinations
PSR Committee 1277
On 13 March 2024 a final determination came into effect regarding a dermatologist. The practitioner was directed to:
- be reprimanded
- be counselled
- repay the amount of $1,946,352.15 to the Commonwealth in respect of MBS items 105, 14050 and 14053 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 14050 for a period of 18 months
In relation to the MBS item 105 services the Committee made findings based on the medical record being inadequate and, in relation to one service, there was no record of an MBS item 105 service being provided on the date of the service.
- the service or treatment provided on behalf of the practitioner did not occur under supervision by the practitioner in accordance with accepted medical practice
- the practitioner’s clinical input into the service was inadequate. Or, if the practitioner did provide adequate clinical input, the record was inadequate in not reflecting the clinical input that was provided
- the medical record was inadequate for other reasons
- in relation to one MBS 14050 service, there was no contemporaneous record of a service meeting the MBS requirements being provided on the date of service
- MBS requirements were not met for some MBS 14053 services as the treatment involved using an Excimer lamp held by hand by the operator who directed the radiation to a very limited portion of skin instead of administration of radiation in a ‘hand and foot cabinet’ as required by the MBS descriptor.
PSR Committee 1306
On 27 March 2024 a final determination came into effect regarding a general practitioner. The practitioner was directed to:
- be reprimanded
- be counselled
- repay the amount of $262,895.31 in respect of MBS items 23, 36, 5020, 5040, 55113, 56223, 56507, 63551, 63650 and 66716 services in connection with which the practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee.
- the medical record was inadequate
- the practitioner’s clinical input into the service was inadequate
- the practitioner’s clinical management was inadequate.
In relation to the MBS item 36 and 5020 services the Committee made findings based on one or more of the following:
- MBS requirements were not met
- the medical record was inadequate in that there was insufficient clinical content recorded to justify an attendance of at least 20 minutes in the case of MBS item 36
- the medical record was otherwise inadequate
- the practitioner’s clinical input into the service was insufficient.
- MBS requirements were not met, including that there was insufficient clinical content recorded to justify an attendance requiring clinical input of at least 20 minutes’ duration or, if there was additional complexity, the record was deficient in failing to record those particulars.
- the medical record was otherwise inadequate.
In relation to the MBS item 55113 services the Committee made findings that there was insufficient clinical indication for initiating an echocardiogram and/or the medical record was inadequate.
In relation to the MBS item 55223 and 56507 services the Committee made findings that in some cases the medical record was inadequate in failing to disclose a clinical indication for initiating the CT scan.
In relation to the MBS item 63650 and 63551 services the Committee made findings that the regulatory requirements of the items were not met and/or the medical record was inadequate.
In relation to the MBS item 66716 services the Committee made findings that there was no clinical indication for ordering thyroid function pathology and/or the medical record was inadequate.
In relation to the PBS item 2335X and 2622B services the Committee made findings based on one or more of the following:
- the practitioner’s medical records in connection with each prescribing episode were inadequate.
- the practitioner’s clinical input was inadequate.
- in respect of PBS item 2335X, PBS requirements were not met and / or the record was inadequate in not explaining how the patient had neuropathic pain, which is a requirement for prescribing pregablin on the PBS.
PSR Committee 1433
On 14 March 2024 a final determination came into effect regarding an optometrist. The practitioner was directed to:
- be reprimanded
- be counselled
- repay the amount of $117,170.72 to the Commonwealth, in respect of MBS items 10910, 10911, 10912, 10913 and 10944 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 10910, 10911 and 10913 for a period of 6 months and MBS items 10912 and 10944 for a period of 12 months.
In relation to the MBS item 10910, 10911, 10912, 10913 and 10944 services the Committee made findings based on one or more of the following:
- MBS requirements were not met, including that a comprehensive examination was not recorded
- the practitioner’s clinical input into the service was inadequate
- the clinical record was otherwise inadequate
- in respect of MBS item 10912 and 10913 services, the service was not clinically indicated
- in respect of MBS 10913 services, MBS requirements were not met, including that the practitioner did not perform a comprehensive assessment and/or the patient had not been seen for an initial consultation in the previous 36 months, as required by the item descriptor.
- in respect of MBS item 10944 services, the MBS requirements were not met, including that the foreign body was not embedded as required by the MBS descriptor.
D. Federal Court
No final decisions concerning PSR were handed down in March 2024.
E. Referrals to the major non-compliance (fraud) division (89A & 106N)
No matters were referred to the major non-compliance (fraud) division in March 2024.
F. Referrals to Ahpra (106XA/B)
No matters were referred to Ahpra in March 2024.