PSR Director's update for April 2024

Published date

31 May 2024

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

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

An agreement with a cardiologist

During the review period, the practitioner provided MBS items 110, 132, 55141 and 55143 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 110, 132, 133, 55126, 55141 and 55143, and had persisting concerns that:

MBS requirements were not always met for MBS items 110 and 132 where services provided were not for initial attendance or initial assessment as required for these items
MBS requirements were not always met for MBS item 133 where the practitioner did not meet minimum time requirements or perform a comprehensive review and modification of an existing treatment and management plan
the practitioner provided MBS items 55126, 55141 and 55143 services where they were not clinically indicated
the practitioner’s record keeping was inadequate for MBS items 55126, 55141 and 55143 including not always providing adequate or accurate reports back to the referring practitioner.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing MBS Items 110, 132, 133, 55126, 55141 and 55143. The practitioner agreed to repay $295,000 and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 24, 5028, 91800, 92024 and 92025 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 5028, 90035 and 91800 and prescribing of PBS item 2622B, and had persisting concerns that:

MBS requirements were not always met for MBS item 91800 services where the practitioner did not take a short patient history where it was clinically relevant
the practitioner’s record keeping was inadequate. The practitioner’s records were often brief and comprised template text that was not sufficiently individualised for the patient
the practitioner prescribed PBS item 2622B at times where it was not clinically indicated and without providing adequate clinical input or appropriate management.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 5028, 90035 and 91800 and prescribing PBS item 2622B. The practitioner agreed to repay $95,000, to be disqualified from providing MBS item 91800 and 91891 services for 12 months and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered a prescribed pattern of services and rendered MBS items 23, 723 and 91891 and prescribed PBS item 1215Y in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of a prescribed pattern of services, rendering of MBS items 23, 721, 723 and 91891 and prescribing of PBS items 1215Y, and had no persisting concerns in relation to MBS item 23. In relation to the remaining items, the Director had persisting concerns that:

the practitioner rendered a prescribed pattern of services and exceptional circumstances were not present
the practitioner did not always meet MBS requirements or provide sufficient clinical input when preparing chronic disease management (CDM) services under MBS items 721 and 723, including when these were prepared by a practice nurse
for some MBS item 91891 services the practitioner did not meet the MBS requirements, provide adequate clinical input or keep adequate records
the practitioner prescribed PBS item 1215Y where the PBS restrictions were not met and without providing appropriate clinical management to patients.

The practitioner acknowledged having engaged in inappropriate practice in providing services in circumstances that constituted a prescribed pattern of services and in connection with rendering MBS items 721, 723 and 91891, and prescribing PBS item 1215Y. The practitioner agreed to repay $285,000 and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered a prescribed pattern of services and rendered MBS items 721, 723, 732, 30029 and 91891 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of a prescribed pattern of services, provision of MBS items 23, 721, 723, 732, 30029 and 91891, and prescribing PBS item 3162K, and had persisting concerns that:

the practitioner rendered a prescribed pattern of services and exceptional circumstances were not present
MBS requirements were not always met for MBS items 23 and 91891 including clinically relevant tasks such as taking history not being undertaken
for MBS item 30029 services the procedure undertaken did not always amount to deep tissue repair of a wound
MBS requirements were not always met for MBS items 721, 723 and 732, including where a patient did not have an eligible chronic disease
when prescribing PBS item 3162K the practitioner did not always provide sufficient clinical input and the practitioner’s record keeping was inadequate in not including information supporting why the prescribing was clinically necessary.

The practitioner acknowledged having engaged in inappropriate practice in providing services in circumstances that constituted a prescribed pattern of services and in connection with rendering MBS items 23, 721, 723, 732, 30029 and 91891 and prescribing PBS item 3162K. The practitioner agreed to repay $615,000 and to be disqualified from providing MBS item 721, 723, 732, 92024, 92025, 92028 and 30029 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 36, 91800, 91801, 91802, 92024, 92025 and 92028 in excess of 99% of their peers. The Director reviewed this practitioner’s provision of MBS items 36, 44, 91800, 91801, 92024, 92025 and 92028, and prescribing of PBS item 10288L, and had no persisting concerns in relation to MBS item 91801 and PBS item 10288L. In relation to the remaining items, the Director had persisting concerns that:

MBS requirements were not always met for MBS items 36, 44, 91800 and 91891, including the respective minimum time requirements
the practitioner did not always meet MBS requirements when providing CDM services under MBS items 92024, 92025 and 92028, including by providing services when the patient may not have been eligible for the services, or did not provide sufficient clinical input for the services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 91800, 92024, 92025 and 92028. The practitioner agreed to repay $78,500 and will be reprimanded by the Director.

An agreement with a psychiatrist

During the review period, the practitioner rendered MBS item 91830 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS item 91830 and had persisting concerns that:

MBS requirements were not always met, including the minimum time requirement
the practitioner did not always provide adequate clinical management of neurodiverse patients
the practitioner’s record keeping was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 91830. The practitioner agreed to repay $136,000 and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered a prescribed pattern of services, and rendered MBS items 3, 5000 and 91890 and prescribed PBS items 1215Y, 2622B, 3162K, 2089K, 8007K and 8254K in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of a prescribed pattern of services, provision of MBS items 3, 23, 91890 and 91891, and prescribing of PBS items 1215Y, 1358L, 2622B, 3162K and 8254K, and had no persisting concerns in relation to PBS item 8254K. The Director had persisting concerns that:

the practitioner rendered a prescribed pattern of services and exceptional circumstances were not present
the practitioner’s records were inadequate in not including sufficient clinical information to explain the services rendered as MBS items 3, 23, 91890 and 91891
the practitioner did not always provide appropriate clinical management to patients when prescribing under the PBS, including when issuing prescriptions without seeing or talking to the patient.

The practitioner acknowledged having engaged in inappropriate practice in providing services in circumstances that constituted a prescribed pattern of services and in connection with rendering MBS items 3, 23, 91890 and 91891, and prescribing PBS items 1215Y, 1358L, 2622B and 3162K. The practitioner agreed to repay $175,000 and will be reprimanded by the Director.

B. PSR Committee final determinations

PSR Committee 1420

On 21 March 2024 a final determination came into effect regarding a neurologist. The practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee in connection with MBS items 110, 11018 and 11003 during the review period.

The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $1,500,000 to the Commonwealth in respect of MBS item 110, 11018 and 11003 services in connection with which the practitioner was found to have engaged in inappropriate practice.

In relation to the MBS item 110 services the Committee made findings based on one or more of the following:

MBS requirements for MBS item 110 were not met, in that no separate neurological consultation was requested, or it was unclear from the information on the referral that a consultation in addition to a nerve conduction study was requested
Where a nerve conduction study was concurrently billed under MBS item 11018, the practitioner’s clinical input was inadequate in that the clinical input in addition to the recorded examination, history and recommendations that were required to perform the nerve conduction study (NCS), was not sufficient to also render an MBS item 110 service. Alternatively, the medical record was inadequate for failing to disclose additional clinical input
The medical record was inadequate in that the practitioner did not document a relevant history, record examinations or make appropriately tailored recommendations
The practitioner’s clinical input was otherwise inadequate.

In relation to the MBS item 11018 services the Committee made findings based on one or more of the following:

The practitioner’s clinical input into the service was inadequate
The practitioner did not have substantial involvement in the service as he did not provide adequate supervision or review of work undertaken by technicians
The practitioner’s reporting of test results was inaccurate or inadequate.

In relation to the MBS item 11003 services the Committee made findings based on one or more of the following:

The practitioner’s clinical input into the service was inadequate including because there were contraindications for performing sleep deprived studies on particular patients without visual observation
The reporting of test results was inadequate
The electroencephalogram (EEG) did not involve routine components of a diagnostic EEG and/or was not carried out in a clinically appropriate way
An appropriate clinical indication for prolonged EEG was not established. In some instances a standard EEG was requested, and the referral was amended to a prolonged EEG, on what appeared to be a financial, rather than a clinical basis.

PSR Committee 1441

On 28 February 2024 a final determination came into effect regarding a general practitioner. The practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee in connection with MBS items 23, 36, 721, 723, 2713, 66653, 71164 and 71200 services and prescribing PBS items 2622B, 8254K, 8319W, 3162K and 8611F during the review period.

The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $544,800 to the Commonwealth in respect of MBS items 23, 36, 721, 723 and 2713 services in connection with which the practitioner was found to have engaged in inappropriate practice
be disqualified from rendering MBS item 721, 723, 92024 and 92025 services for a period of 12 months.

In relation to the MBS item 23 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that there was insufficient clinical content to justify a Level B consultation
The practitioner’s clinical input into the service was insufficient
The medical record was inadequate.

In relation to the MBS item 36 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that there was no clinical content recorded to reflect a consultation of at least 20 minutes’ duration
The practitioner’s clinical input into the service was insufficient
The medical record was inadequate.

In relation to the MBS item 721 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that the GP Management Plan (GPMP) was not a comprehensive plan to manage the patient’s chronic conditions, the patient did not have a chronic condition as required, and/or the GPMP contained inaccurate information
The GPMP document did not record any meaningful clinical input as at the date of service
The medical record was otherwise inadequate.

In relation to the MBS item 723 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that the patient was not eligible for an MBS item 723 service where the patient did not have a chronic condition, the Team Care Arrangements (TCA) document was generic and not adequately individualised for the patient and/or there was no evidence of collaboration with 2 other health care providers
The medical record was inadequate.

In relation to the MBS item 2713 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that the record did not reflect a consultation involving a mental health disorder of at least 20 minutes’ duration
The practitioner’s clinical input into the service was inadequate
The medical record was inadequate.

In relation to the MBS item 66653, 71164 and 71200 services the Committee made findings based on one or more of the following:

There was no clinical indication for the test to be ordered
The medical record was inadequate in respect of MBS items 71164 and 71200 services

In relation to the PBS item 2622B and 3162K services the Committee made findings based on one or more of the following:

The practitioner’s clinical input into the service was insufficient
The medical record was inadequate.

In relation to the PBS item 8254K and 8319W services the Committee made findings based on one or more of the following:

The prescription of amoxicillin and clavulanic acid for the patient was not clinically indicated
The medical record was inadequate.

In relation to the PBS item 8611F services the Committee made findings based on one or more of the following:

There was insufficient clinical input recorded to support a clinical indication for prescribing Tramadol or appropriate management of the prescribing
The medical record was inadequate.

PSR Committee 1492

On 13 March 2024 a final determination came into effect regarding a general practitioner. The practitioner was found to have engaged in inappropriate practice in a final report of a PSR Committee in connection with MBS items 707, 721, 723, 732, 2713, 10997, 11700 and 92072 during the review period.

The practitioner was directed to:

be reprimanded
be counselled
repay the amount of $262,500 to the Commonwealth in respect of MBS items 707, 721, 723, 732, 2713, 10997, 11700 and 92072 services in connection with which the practitioner was found to have engaged in inappropriate practice
be disqualified from rendering MBS item 707 services for a period of 36 months, MBS item 721, 723, 92024 and 92025 services for a period of 18 months, MBS item 732, 2713, 92028, 92115 and 92127 services for a period of 12 months, and MBS item 10997 services for a period of 6 months.

In relation to the MBS item 707 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including where the practitioner:
- did not provide a comprehensive health assessment or management plan that was prepared and provided to the patient,
- did not take a comprehensive history from the patient,
- did not undertake a comprehensive examination, and/or
- did not render sufficient clinical input to justify a 60 minute consultation
the practitioner’s clinical input into the service was insufficient
The medical record was inadequate.

In relation to the MBS item 721 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including that the GPMP was not a comprehensive plan to manage the patient’s chronic conditions and the GPMP did not contain up to date information regarding the patient’s chronic health conditions
The practitioner’s clinical input into the service was inadequate
The medical record was otherwise inadequate.

In relation to the MBS item 723 services the Committee made findings based on one or more of the following:

The MBS requirements were not met, including where:
- there was no evidence of two-way communication with at least two other health care providers involved in the patient’s care for any reviewed services, and/or
- there were no plans that involved a team of health care professionals participating in a patient’s care, setting out the treatment services and goals for the patient, and what actions would be taken by the members of the team and by the patient.
Alternatively, if there was two-way communication, and plans containing team care goals and services were formulated, the practitioner’s medical records were inadequate for failing to document this.

In relation to the MBS item 732 services the Committee made findings based on one or more of the following:

MBS requirements were not met, in that:
- where the review was of a GPMP, there was no indication of what in the plan was being reviewed. Due to the generic nature of the goals in the GPMP, the practitioner did not undertake meaningful review of the patient’s progress against those goals, and/or
- where the review was of a TCA there was no evidence of two way communication with the other health care providers involved in the patients’ care and necessary amendments were not made to the TCAs.
There was insufficient clinical input, including that there were inadequate amendments made to the patient’s plan
If further clinical input was provided during the service, the medical record was inadequate in failing to record it.

In relation to the MBS item 2713 services the Committee made findings based on one or more of the following:

MBS requirements were not met, including where:
- there was not sufficient clinical content recorded to justify a consultation of at least 20 minutes, and/or
- the record did not reflect at least 20 minutes of clinical input with respect to a mental health disorder including where MBS item 2713 services were co-billed with other MBS items. The content in the records did not reflect that the MBS requirements for the MBS item 2713 services and the co-billed services were both met.
The practitioner’s clinical input into the service was either inappropriate, or inadequate.
The practitioner’s management of the patient was inadequate.

In relation to the MBS item 10997 services the Committee made findings based on one or more of the following:

MBS requirements were not met including that the services were not provided where a patient already had a GPMP, TCA or multidisciplinary care plan in place when billed on its own or, when co-billed with another MBS service, the content in the records did not reflect that the MBS requirements for MBS 10997 and the co-billed services were both met
In one service the record showed that the patient was in hospital on the day of service and so did not attend the practitioner’s practice on this day.

In relation to the MBS item 11700 services the Committee made findings based on one or more of the following:

There was no clinical indication for an electrocardiogram
The practitioner’s input into the service was inadequate
The medical record was inadequate.

In relation to the MBS item 92072 services the Committee made findings based on one or more of the following:

The MBS requirements for a review of a GPMP or a TCA were not met in that:
- where the review was of a GPMP, there was no review of the matter set out in the plan. Due to the generic nature of the goals in the GPMP, the practitioner did not undertake a meaningful review of the patient’s progress against the goals.
- where the review was of a TCA there was no evidence of two way communication with two other health care providers involved in the patient’s care, as required by the MBS item descriptor. In addition, necessary amendments to the client’s plan were not included in the TCA.
The practitioner provided insufficient clinical input into the service
If further clinical input was provided during the service, the medical record is inadequate in failing to record it.

C. Federal Court

Dik v Director of Professional Services Review [2024] FCA 370

Dr Dik sought judicial review of:

the Final Determination of the Determining Authority (DA), which had ordered repayment of over $500,000 and disqualification from certain MBS items for 18 months, and
the Final Report of the PSR Committee, which had found inappropriate practice in connection with rendering 14 different MBS items.

In order for the Court to consider these matters, Dr Dik sought leave to extend time to make the applications. His application was a few days late in relation to the DA’s Final Determination, and 388 days late in relation to the Committee’s Final Report. The Director did not oppose an extension of time in relation to the DA’s decision but opposed an extension of time in relation to the Committee’s Final Report.

The Court dismissed the application for extension of time to challenge the Committee’s Final Report, stating that the PSR scheme assumes litigation would be commenced upon completion of the particular stage concerning which the person is aggrieved rather than waiting until the end of the final stage. The Court also noted that the proposed challenge to the Committee’s Report had no merit and so did not support an extension of time.

The Court dismissed the challenge to the DA’s Final Determination indicating that the DA had considered all the matters put to it by Dr Dik and had not acted unreasonably in making the directions it made in the Final Determination. The directions were ‘squarely within the Determining Authority’s decisional freedom’, and there was a logical connection between those directions and the findings by the Committee of inappropriate practice.

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

No matters were referred to the major non-compliance (fraud) division in April 2024.

E. Referrals to Ahpra (106XA/B)

1 matter was referred to Ahpra in April 2024.