PSR Director's update for December 2024

Published date

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

12 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 80 or more professional attendances per day on each of 25 days in breach of the prescribed pattern of services ‘80/20 rule’. The practitioner was also nationally ranked 1st for rendering MBS items 731 (contribution by a general practitioner to a multidisciplinary care plan) and 90020 (level A consultation at a residential aged care facility (RACF)). The Director reviewed the practitioner’s rendering of MBS items 23 (level B consultation), 36 (level C consultation), 703 (health assessment lasting at least 30 minutes but less than 45 minutes), 721 (GP management plan (GPMP), 723 (team care arrangement (TCA)), 731, 903 (participation by a general practitioner in a medication management review at an RACF), 90020 and 90035 (level B consultation at an RACF) and the prescribed pattern of services. The Director found there were exceptional circumstances for the days during the review period on which the practitioner rendered 80 or more services, had no persisting concerns about MBS item 90035, but had persisting concerns that: 

  • The practitioner’s record-keeping was inadequate. For example, some of the practitioner’s clinical notes were very brief, sometimes only recording prescriptions issued or investigations ordered and where template text or hot keys were used little other clinical information, such as history, examination findings, management plan or preventative health care advice was included in notes.
  • For some MBS item 731 and 90020 services, the practitioner may not have always attended to the patient and for many MBS 721, 723 and 731 services, plans and documents appeared to be the same as for previous services with little or no changes made. 
  • For some MBS item 723 services there was no record entry for the date of service and no document relating to the TCA in the record 
  • MBS requirements were not always met, including minimum time requirements where relevant.
  • For some services, the practitioner’s clinical input was inadequate. For example, the practitioner at times reissued prescriptions without assessing the conditions for which they were prescribed.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 703, 721, 723, 903 and 90020. The practitioner agreed to be counselled by the Director, repay $300,000, be disqualified from providing MBS items 703 and 92024 for 12 months and providing MBS items 721 and 903 for 9 months. 

An agreement with a Medical Practitioner. 

During the review period the practitioner was ranked 1st nationally for rendering MBS item 45585 (liposuction). The Director reviewed this practitioner’s rendering of 45585, 55244 and 55246. The Director had persisting concerns that:

  • The practitioner’s record-keeping was inadequate. For example, the practitioner’s handwritten notes were not always sufficiently comprehensible to other practitioners, and for MBS items 55244 and 55246 the practitioner did not always keep a copy of reports of investigations initiated
  • MBS requirements for item 45585 were not met in that the patient did not always have lymphoedema
  • MBS items 55244 and 55246 services were not always clinically relevant or initiated with a written request, and
  • The practitioner may have received a benefit as inducement for making imaging requests contrary to Part IIBA of the Act. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 45585, 55244, and 55246. The practitioner agreed to be counselled by the Director, to repay $121,000 and to be disqualified from providing MBS item 45585 services for 24 months. 

An agreement with an Ophthalmologist. 

During the review period, the practitioner rendered MBS items 11219 (optical coherence tomography), 11221 (full quantitative computerised perimetry), 11241 (orbital contents, ultrasonic perimetry) and 42788 (laser capsulotomy) in excess of 99% of their peers. The Director reviewed the practitioners rendering of MBS items 11219, 11221, 11241, 42702 (lens extraction and insertion of intraocular lens), 42738 (paracentesis of anterior chamber or vitreous cavity) and 42788. The Director had persisting concerns that: 

  • MBS items 11219, 11221 and 11241 services, tests were not always clinically relevant and were performed routinely as part of practitioner’s clinic procedures, rather than being necessary for the treatment of patients’ presenting problems.
  • MBS item 42788 services were not clinically indicated. It appeared that laser capsulotomies were done routinely for every patient who had cataract surgery. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 11241 and 42788. The practitioner agreed to be counselled by the Director and repay $178,000.

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS items 715 (health assessment of patient of Aboriginal or Torres Strait Islander descent), 721, 723, 5020 (afterhours level B consultation) and 90035 in excess of 99% of their peers and the practitioner’s volume of total and daily services was disproportionate to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 715, 721, 723, 5020, 5023 (afterhours level B consultation outside consulting rooms) and 90035. The Director had persisting concerns that 

  • MBS requirements were not always met, including minimum time requirements where relevant, MBS item 721 services were not comprehensive plans for managing chronic disease and for MBS item 723 there was no evidence of communication with two collaborating TCA members.
  • The practitioner’s record-keeping was inadequate. For example, a record entry was not always able to be located for services and templates used were not always sufficiently individualised for the patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 715, 721, 723, 5020, 5023 and 90035. The practitioner agreed to be reprimanded by the Director, repay $480,000 and to be disqualified from providing MBS item 721, 723, 92024 and 92025 services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner was ranked 1st and 2nd nationally for the provision of MBS items 5067 (level D consultation at an RACF afterhours) and 90051 (level D consultation at an RACF) respectively, and rendered MBS items 44 (level C consultation), 743 (attendance to organise and coordinate a multidisciplinary case lasting at least 40 minutes), 5067 (level D attendance at RACF) , 90043 and in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 743, 5067, 90043, 90051 and 91801. The Director had persisting concerns that:

  • MBS requirements were not always met including minimum time requirements where relevant and item 5067 services were not always rendered during an after-hours period. 
  • The practitioner’s record keeping was inadequate, including that entries were brief and did not include sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 36, 44, 743, 5067, 90043, 90051 and 91801. The practitioner agreed to be reprimanded by the Director, to repay $635,000, and to be disqualified from providing MBS item 44, 743, 5067, 90043, 90051, 91801, 91802, 91900, 91910 services for 12 months. 

An agreement with a Medical Practitioner. 

During the review period, the practitioner rendered MBS items 90035, 90043 and 90051 services in excess of 99% of their peers and rendered 60-69, 70-79, 80-89 and more than 90 professional attendances at RACFs residential aged care facilities disproportionately to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 90035, 90043 and 90051 services. The Director had persisting concerns that:

  • MBS requirements were not met for some MBS item 23 and 36 services. For example, there was insufficient clinical input to justify the billing of a Level B or Level C attendance and minimum time requirements for MBS item 36 were not always met 
  • The practitioner may not always have attended patients for MBS item 90035 services and there were no notes of the attendance made by the practitioner 
  • The practitioner’s record keeping was inadequate. For example, for some services, the record entries lacked adequate patient history and current medication details.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36 and 90035. The practitioner agreed to be reprimanded and counselled by the Director, repay $230,000, and to be disqualified from providing MBS item 36, 91801, 91900 (level C telephone attendance) services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 23, 721 and 723 services in excess of 99% of peers. The Director reviewed this practitioner’s rendering of MBS items 23, 705 (health assessment lasting at least 45 minutes but less than 80 minutes), 707 (health assessment lasting at least 60 minutes), 721, 723, 2715 (attendance for GP mental health treatment plan lasting at least 20 minutes but less than 40 minutes) and 91891 (level B telephone attendance), The Director had persisting concerns that:

  • MBS requirements were not always met including minimum time requirements where relevant, and MBS item 707 services did not always involve extensive examination
  • The practitioner did not always attend on patients when providing MBS item 721 and 723 services
  • The practitioner’s clinical input was not always adequate, including prescribing potentially addictive drugs without advising patients about drug interactions, risks and appropriate use
  • The practitioner’s record keeping was inadequate including that entries were brief and did not include sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 705, 707, 721, 723, 2715 and 91891. The practitioner agreed to repay $485,000, to be disqualified from providing MBS item 721, 723, 2715, 92024, 92025, 92116 and 92127 services for 12 months, and be reprimanded by the Director. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS item 5020, 90035, 91891 services, in excess of 99% of their peers and rendered a volume of total and daily services disproportionate to peers. The Director reviewed the practitioners rendering of MBS 23, 5020, 90035 and 91891. The Director had persisting concerns that: 

  • MBS requirements were not always met. For example, for some services there was insufficient clinical input to justify the billing of a Level A or Level B attendance 
  • The practitioner’s record keeping was inadequate. For example, record entries did not always contain sufficient clinical information to explain the service and frequently relied on hotkey entries that were not sufficiently individualised for the patient.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 23, 90035, and 91891. The practitioner agreed to be counselled by the Director, repay $360,000 and be disqualified from providing MBS item 91891. 

An agreement with a Paediatrician 

During the review period, the practitioner rendered MBS items 122 (attendance other than at consulting rooms), 128 (attendance at a place other than consulting rooms or hospital, after the first in a single course of treatment), 92422 (telehealth initial assessment for a patient with 2 or more comorbidities, prepare a treatment and management plan, lasting at least 45 minutes) and 92423 (telehealth subsequent assessment for a patient with at least 2 morbidities, review a treatment and management plan, lasting at least 20 minutes) in excess of 99% of their peers and rendered MBS items 132 (initial assessment for a patient with 2 or more comorbidities, prepare a treatment and management plan, lasting at least 45 minutes) and 133 (subsequent assessment for a patient with at least 2 morbidities, review a treatment and management plan, lasting at least 20 minutes) in excess of 98 and 97% of their peers respectively. The Director reviewed the practitioners rendering of MBS item 128, 132, 133, 91825, 92422 and 92423. The Director had no persisting concerns for MBS item 133 and 92423 and had persisting concerns that: 

  • The practitioner did not always attend the patient on the date of service for MBS item 128, 91825 and 92423 services, 
  • MBS item requirements were not always met for MBS items 128, 132 and 92422. For example, for some MBS item 128 services there was no in-person attendance on the patient for services that were provided by telehealth instead and for MBS item 92422 the attendance was not always an initial attendance in a course of treatment.
  • The practitioner’s record keeping was inadequate. For example, for some MBS item 92422 telehealth services it was not clear that the records accurately reflected information from the service such as how the practitioner was able to take blood pressure and heart rate for the patient that was recorded. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 128, 132, 91825 and 92422. The practitioner agreed to be counselled by the Director, repay $72,000, and to be disqualified from providing MBS item 128 services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered MBS items 705, 707, 731, 735 (attendance to organise and coordinate a multidisciplinary case conference lasting at least 15 minutes but less than 20 minutes), 747 (attendance to participate in a multidisciplinary case lasting at least 15 minutes but less than 20 minutes), 90035 and 90051 in excess of 99% of their peers and the practitioner’s volume of total and daily services was disproportionate to their peers. The Director reviewed this practitioner’s rendering of MBS items 705, 707, 731, 735, 743, 5028, 90035, 90043, 90051 and 91891. The Director had persisting concerns that

  • MBS requirements were not always met. For example, the practitioner did not always undertake tasks where they were clinically relevant as required by the MBS item descriptor. 
  • The practitioner’s record keeping was inadequate. For example, records were often reliant on generic templates which were not sufficiently individualised for the patient and the practitioner’s records were not sufficiently comprehensible to allow another practitioner to effectively continue care in reliance of the record.
  • Not all MBS item 5028, 90035, 90043 and 90051 services were clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 705, 707, 731, 735, 743, 5028, 90035, 90043, 90051 and 91891. The practitioner agreed to be reprimanded and counselled by the Director, repay $470,000 and to be disqualified from providing MBS item 705, 707, 731, 735, 743, 92027 and 91891 services for 12 months. 

An agreement with a General Practitioner. 

During the review period, the practitioner rendered 30 or more relevant phone attendances on each of 22 days in breach of the prescribed pattern of services ‘30/20 rule’. The Director reviewed this practitioner’s rendering of MBS items 91890 and 91891 and the prescribed pattern of services. The Director had persisting concerns that

  • Exceptional circumstances did not exist for any of the 22 days during the review period on which the practitioner rendered 30 or more phone services
  • MBS requirements were not always met including minimum time requirements for MBS item 91891 and taking a short patient history for MBS item 91890 
  • The practitioner’s clinical input was not always adequate. For example, the practitioner did not always appropriately manage their patients’ health issues including not discussing abnormal test results or side effects of some medication with patients
  • The practitioner’s record keeping was inadequate. For example, the practitioner’s clinical notes often included template text that did not adequately explain what occurred during consultations.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 91890 and 91891, and in providing services that constituted a prescribed pattern of services. The practitioner agreed to be counselled by the Director and repay $7,500. 

An agreement with a General Practitioner. 

 During the review period, the practitioner rendered 30 or more relevant telephone attendances on each of 21 days during the review period in breach of the prescribed pattern of services ‘30/20 rule’.. The Director reviewed this practitioner’s rendering of MBS 91890 and 91891. The Director had persisting concerns that 

  • Exceptional circumstances did not exist on the 21 days on which the practitioner rendered a prescribed pattern of services.
  • The MBS minimum time requirement was not always met for MBS item 91819.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 91891, and in providing services that constituted a prescribed pattern of services. The practitioner agreed to be counselled by the Director and repay $20,000.

B. No further action decisions

Request to review a Respiratory and Sleep Medicine Specialist

During the review period, the practitioner rendered MBS item number 41764, including items in association, disproportionately to their peers.

The Director reviewed a random sample of services rendered as MBS items 110, 116, 132, 11503, 11507 and 41764. After reviewing the practitioner’s records and meeting with the practitioner, 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

No final determinations came into effect in December 2024.

D. Federal Court

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

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

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

F. Referrals to AHPRA (106XA/B)

3 matters were referred to AHPRA in December 2024.

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