PSR Director's update for November 2024

Published date

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

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

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 732 (review of GP management plan (GPMP) or team care arrangements TCA)), 91891 (phone consultation lasting at least 6 minutes) and 92127 (phone consultation in relation to a mental health disorder lasting at least 20 minutes) in excess of 99% of their peers and rendered a volume of total and daily services disproportionate to peers. The Director reviewed this practitioner’s rendering of MBS items 23 (level B consultation), 732, 5020 (level B consultation afterhours), 91891 and 92127. The Director had persisting concerns that

  • the record keeping was inadequate, with many records including excessive input by way of ‘hotkey’ entry that had not been sufficiently individualised to the patient and the clinical content of the attendance, 
  • the MBS requirements were not always met for the services, including minimum time requirements where relevant,
  • the practitioner did not provide sufficient clinical input for some services. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 732, 5020, 91891 and 92127. The practitioner agreed to be counselled by the Director, repay $350,000, and to be disqualified from providing MBS item 732 and 92028 services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 45563 (neurovascular island flap for restoration of essential sensation in the digits or sole of the foot, or for genital reconstruction), in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36 (level C consultation), 31363 (surgical excision and repair of malignant skin lesion), 45451 (full thickness skin graft to one defect, 5mm or more) and 45563, and PBS items 3119E (cefalexin). The Director had no persisting concerns with MBS item 36 and had persisting concerns that

  • MBS requirements were not met, including the requirements for a neurovascular island flap for MBS 45563 services 
  • there was not always a clinical indication for MBS item 45451 services
  • the practitioner excised an excessive amount of skin than was necessary for the lesion size for MBS item 31363 services
  • the practitioner did not always meet PSB item 3119E restrictions when prescribing 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 31363, 45451 and 45563 and prescribing PBS Items 3119E. The practitioner agreed to repay $32,500 and be counselled by the Director. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS items 23, 36 and 44 (level D consultation) in excess of 99% of peers, a volume of total and daily services disproportionate to peers and  initiated MBS item 66596 (iron studies)  in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 721(GPMP), 723 (TCAs), 66596, 91891 and 92746 (level C phone consultation for a person in a COVID-19 Commonwealth declared hotspot or in COVID-19 isolation or quarantine because of a state or territory public health order), and PBS item 2622B (oxycodone), The Director had persisting concerns that

  • the record keeping was inadequate, with many records not providing sufficient clinical detail to explain what occurred during the service, including GPMP management plans and TCA documents,
  • the MBS requirements were not always met for the services, including minimum time requirements where relevant
  • there was no clinical indication for initiating some MBS item 66596 services
  • the practitioner’s clinical input was inadequate for some services 
  • the practitioner did not always provide adequate clinical management when prescribing PBS item 2622B

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 44, 721, 723, 66596, 91891 and 92746 and prescribing PBS Item 2622B. The practitioner agreed to be counselled by the Director, repay $495,000, and to be disqualified from providing MBS item 91891 services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 23 and 91891 in excess of 99% of their peers and a volume of total and daily services disproportionate to peers. The Director reviewed this practitioner’s rendering of MBS items 23 and 91891. The Director had persisting concerns that

  • MBS requirements were not met including minimum time requirements where relevant .
  • record keeping was inadequate, and frequently included excessive input by way of ‘hotkey’ entry that was not sufficiently individualised for the patient and the clinical content of the attendance. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23 and 91891. The practitioner agreed to repay $152,000, and to be disqualified from providing MBS item 91891 services for 6 months. 

An agreement with an Oral and Maxillofacial Surgeon. 

During the review period, the practitioner was ranked first nationally for rendering MBS items 45200 (single stage local skin flap), 45815 (operation on mandible or maxilla) and 45829 (reduction of maxillary tuberosity), and first compared to their peers for item  30023 (wound debridement), The Director reviewed this practitioner’s rendering of MBS items 18234 (trigeminal nerve block of primary branch), 30023, 45200, 45815 and 45829. The Director had persisting concerns that

  • the record keeping was inadequate, including a lack of operation notes, referral letters and letters to referring practitioners where relevant  
  • the MBS requirements were not always met for the services including not injecting the primary branch of the trigeminal nerve for MBS item 18234 services,
  • the services were not always clinically indicated for MBS item 45200

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 18234, 30023, 45200, 45815 and 45829. The practitioner agreed to be counselled by the Director, to repay $150,000, and to be disqualified from providing MBS item 18234, 30023, 45815, 45829 services for 3 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 91890 in excess of 99% of their peers and rendered 30 or more telephone attendance items on each of 24 days in breach of the prescribed pattern of services “30/20 rule”. The Director reviewed this practitioner’s rendering of MBS items 91890 (phone consultation lasting less than 6 minutes) and 91891 and the prescribed pattern of service. The Director had no persisting concerns in relation to MBS items 91890 and 91891 but had persisting concerns that

  • the practitioner rendered a prescribed pattern of services and there were no exceptional circumstances present that affected the rendering of these services on any of the 24 days. 

The practitioner acknowledged having engaged in a prescribed pattern of services and agreed to be counselled by the Director. 

B. No further action decisions 

There were no decisions to take no further action in November 2024.

C. PSR Committee final determinations 

PSR Committee 1412

On 28 November 2024 a final determination came into effect regarding a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS items 35 (consultation at a residential aged care facility (RACF) lasting less than 20 minutes by a general practitioner), 585 (urgent afterhours attendance), 594 (attendance on additional patient at urgent afterhours attendance), 599 (urgent afterhours attendance in unsociable hours) and 5028 (afterhours consultation at a RACF lasting less than 20 minutes by a medical practitioner), services during the review period.

The practitioner was directed to:

  • repay the amount of $10,000 to the Commonwealth in respect of MBS item 35, 585, 594, 599 and 5028 services in connection with which the practitioner was found to have engaged in inappropriate practice. 

In relation to the MBS item 35 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met, including that there was inadequate history, examination and management recorded where this was clinically relevant.
  • The medical record was inadequate, including that there was no entry for the date of service, the record did not explain the service or clinical input provided by the practitioner and/or the level of clinical input recorded was inadequate.

In relation to the MBS item 585 services the Committee made findings based on one or more of the following:

  • The MBS requirements were not met, in that the patient did not need urgent clinical assessment of a condition that may deteriorate before the next in hours period.
  • The medical record was inadequate, including in relation to the clinical input recorded.

In relation to the MBS item 594 services the Committee made findings on the basis that the medical record was inadequate, including that the clinical input recorded was insufficient.

In relation to the MBS item 599 services the Committee made findings based on one or more of the following:

  • The MBS requirements were not met, in that the patient did not need urgent clinical assessment of a condition that may deteriorate before the next in-hours period.
  • The practitioner’s clinical input into the service was insufficient.
  • The medical record was inadequate, including that it was not sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s care.

In relation to the MBS item 5028 services the Committee made findings on the basis that the medical record was inadequate, including that it was not sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s care.

PSR Committee 1495

On 28 November a final determination came into effect regarding a general practitioner.  In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS items 23, 14100 (laser photocoagulation using laser radiation in the treatment of vascular abnormalities of the head or neck), 30192 (treatment of 10 or more premalignant skin lesions by ablative technique), 30196 (removal of malignant neoplasm of skin or mucous membrane) and 45201 (muscle, myocutaneous or skin flap, where clinically indicated to repair one surgical excision made in the removal of a malignant or non-malignant skin lesion) services during the review period.

The practitioner was directed to:

  • be reprimanded 
  • be counselled 
  • repay the amount of $200,000. This reflects approximately 60% of the benefits paid for the MBS item 23, 14100, 30192, 30196 and 45201 services in connection with which he was found to have engaged in inappropriate practice (subparagraph 106U(1)(cb) of the Act), and
  • the practitioner be disqualified from rendering:
    • MBS item 14100, 30192 and 45201 services for a period of 12 months, and
    • MBS item 30196 services for a period of 3 months,

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

  • The practitioner’s clinical input into the service was insufficient or inadequate.
  • On two occasions, when co-billed with another item there was no separate consultation on the date of service.
  • The medical record was inadequate.

The Committee’s findings for the MBS item 14100 services in relation to which the practitioner was found to have engaged in inappropriate practice were for one or more of the following reasons: 

  • The MBS item requirements were not met, including that:
  • The practitioner did not attend the patient on the date of service.
  • The practitioner’s supervision arrangements in relation to the service were inadequate.
  • There were no photographs included in the record.
  • The medical record was inadequate, including in relation to a lack of patient consent and/or the practitioner attending the patient prior to the course of treatment.

In relation to the MBS item 30192 services the Committee made findings based on one or more of the following: 

  • The medical record was inadequate, including that:
    • The lack of personalisation in the notes made it unclear what occurred during the consultation.
    • It was unclear how many lesions were treated.
    • There was no record that other possible treatment options were discussed with the patient as part of obtaining informed consent.

In relation to the MBS item 30196 services the Committee made findings based on one or more of the following: 

  • The medical record was inadequate, including that:
    • The site and nature of the lesion being treated was inadequately described.
    • It was not clear from the record if the MBS requirements were met, in relation to serial curettage.
    • There was no record of any alternative treatment options discussed with the patient or follow-up advice.
  • The MBS requirements were not met, in that full excision of the lesion did not occur.
  • The practitioner’s clinical input into the service was inadequate.
  • The service was not clinically indicated.

In relation to the MBS item 45201 services the Committee made findings based on one or more of the following: 

  • The MBS requirements were not met, including that:
    • There was no documentation of the procedure performed on the date of service.
    • The location and characteristics of the lesion were inadequately or incorrectly described.
    • Patient consent was not recorded.
    • The practitioner’s record of the patient’s medications and co-morbidities, and any follow-up advice or management, was inadequate.

D. Federal Court

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

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

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

F. Referrals to AHPRA (106XA/XB)

No matters were referred to AHPRA in November 2024.

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